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PLA  TE  I. 


Practice  of  Medicine  —  French. 


Fig  A. 


^''-A,.      ^*- 


''^rf-W^' 


4 


FigB. 


2  ^i??>^' 


1 


THE   BLOOD   IN    LEUKEMIA. 

FIG  A  Splenomyelogenous  Leukemia:  yellow  cells,  erythrocytes;  1,  Polymor- 
phonuclear NEUTROPHILES;  2,  EOSINOPHILES  ;  3,  LYMPHOCYTE  ;  4,  MYELOCYTES  ; 
5.  NUCLEATED  ERYTHROCYTES. 

FIG.  B.  LYMPHATIC  LEUKEMIA:  YELLOW  CELLS,  ERYTHROCYTES  ;  1,  POLYMORPHONUCLEAR 
NEUTROPHILE.  ALL  OTHER  CELLS  ARE  LARGE  OR  SMALL  LYMPHOCYTES. 


A  TEXT-BOOK 


ON  THE 


PRACTICE  OF  MEDICINE 


Designed  for  the  Use  of  Students 


JAMES   MAGOFFIN    FRENCH,  M.D. 

Lecturer  on  the  Theory  and  Practice  of  Medicine,  Medical  College  of  Ohio  ;  Attending 

Physician,  St.  Mary's  Hospital ;  Consulting  Physician,  St.  Francis 

Hospital  for  Incurables ;  Cincinnati. 


ILLUSTRATED   BY  TEN   FULL-PAGE   PLATES  AND  FIFTY 
WOOD-ENGRAVINGS 


NEW    YORK 
WILLIAM  WOOD  AND  COMPANY 

MDCCCCni 


Copyright,  1903 
By  WILLIAM  WOOD  &  COMPANY 


THE    PUBLISHERS'    PRINTING    COMPANY 
NEW   YORK 


PREFACE. 

There  are  many  excellent  textbooks  on  the  Practice  of  Medicine. 
Nevertheless,  an  experience  of  nearly  twenty-five  years  as  an  instructor 
has  convinced  me  that  a  book  of  the  character  of  this  one  cannot  fail 
to  meet  the  requirements  of  medical  students.  It  has  been  my  aim  to 
state  only  the  facts  of  medicine  accepted  by  the  best  authorities,  and  to 
express  them  in  simple,  concise  language,  and,  as  far  as  possible,  in 
logical  sequence.  Personal  experience  has  been  kept  in  the  background, 
and  the  pleasant  diversion  of  case  reports  has  been  entirely  omitted. 
The  names  of  authorities  have  been  given  only  when  it  seemed  improper 
to  omit  them.  While  I  am  indebted  to  all  the  recent  textbooks  and 
larger  treatises,  and  although  I  have  scanned  the  current  periodicals, 
I  have  endeavored  to  make  use  of  only  the  established  facts,  omitting 
discoveries  that  rest  solely  upon  theory  or  undemonstrated  observa- 
tions. 

Both  the  English  and  metric  systems  of  weights,  measures,  and  tem- 
peratures are  given  throughout  the  text,  the  metric  system  in  paren- 
theses. When  the  exact  equivalent  is  unimportant,  the  nearest  round 
number  is  given,  as  an  aid  to  memory. 

Part  I,  entitled  Principles  of  Medicine,  is  inserted  for  the  purpose  of 
affording  the  student  a  convenient  means  of  refreshing  his  memory  in  the 
pathological  processes  constantly  recurring  in  the  study  of  diseases. 
And  it  is  hoped  that  Part  III,  on  Clinical  Methods,  will  serve  the  same 
end  and  prove  of  continued,  if  not  of  greater,  value,  after  the  erstwhile 
student  has  attained  to  the  higher  station  of  a  practicing  physician. 

JAMES  M.   FRENCH. 
Cincinnati,  September  i,  1903. 


CONTENTS. 


PART  I. 

Principles  of  Medicine. 

PAGE 

Disease 3 

Classification  of  Diseases  (Nosology) 4 

Causes  of  Disease  (Etiology) 5 

Pathology 7 

Disturbances  of  Nutrition  and  Metabolism 7 

Generalization  of  Disease 8 

Changes  in  the  Blood  and  Circulation 9 


Fever. 


19 


Retrograde  Processes 20 

Inflammation 29 

Regeneration 31 

The  Bacteria  of  Disease      .        . 32 

General  Bacteriology 32 

Pathogenic  Bacteria 36 

Infection 37 

Antagonism  of  Infection 39 

■  Immunity 42 


PART  II. 

Practical  Medicine. 

SECTION  I. 

The  Infectious  Diseases. 

Typhoid  Fever 47 

Typhus  Fever 78 

Relapsing  Fever 80 

Influenza  (La  Grippe) 82 

Dengue 84 

Cholera 86 

Yellow  Fever 89 

Plague 94 

Climatic  Bubo 97 


viii  CONTENTS 

PAGE 

Malta  Fever ny 

Beriberi g8 

Scarlet  Fever loo 

Measles .        .        .106 

German  Measles  (Rdtheln) 109 

Rubella  Scarlatinosa  ("Fourth  Disease") no 

Cerebrospinal  Meningitis .111 

Pneumonia 115 

Diphtheria 129 

Diphtheroid 141 

Whooping-Cough 142 

Mumps 144 

Septicemia .        .        .146 

Pyemia 150 

Erysipelas 151 

Acute  Rheumatism       .        .        .        .        ,        .        .      _.        .        .        .154 

Gonorrheal  Infection    .        .        . 160 

Syphilis .        .        .162 

Tuberculosis 169 

Leprosy 220 

Tetanus 223 

Infectious  Diseases  of  Doubtful  Nature  .        .        .        .        .        .        .224 

Febricula ,        .224 

Acute  Febrile  Jaundice 225 

Glandular  Fever 226 

Mountain  Fever .227 

Spotted  Fever  of  the  Rocky  Mountains 227 

Miliary  Fever .228 

Infectious  Diseases  Common  to  Man  and  Lower  Animals        .        .      229 

Glanders •.        .        .        .229 

Hydrophobia  .        .        . 230 

Anthrax    .        . .        .        .      2;^2 

Actinomycosis .        .        -235 

Psittacosis 236 

Milk  Sickness  . .        .327 

Foot  and  Mouth  Disease     . .      237 

SECTION  11. 
Diseases  Due  to  Animal  Parasites. 

Protozoan  Diseases 239 

Malaria 239 


CONTENTS  ix 

PAGE 

Dysentery 249 

Smallpox          .        .        .*       .        . 256 

Vaccination .  265 

Chickenpox 266 

Psorospermiasis 268 

Infusoria 268 

Trematodes  (Distomiasis) 269 

Diseases  Caused  by  Nematodes 270 

Ascariasis 270 

Trichinosis 271 

Ankylostomiasis 275 

Filariasis 276 

Drachontiasis .        ..        .       .        *• 277 

Other  Nematodes 278 

Diseases  Caused  by  Cestodes   .        . 279 

Tape-Worms 279 

Visceral  Diseases 282 

Cysticercus  Cellulosae 282 

Echinococcus  Disease 283 

Parasitic  Arachnids     .        .        .        .        .        .        .        .        =        .        .287 

Larger  Parasitic  Insects     .        . 287 

SECTION  III. 
Diseases  of  the  Blood  and  Ductless  Glands. 

Diseases  of  the  Blood 289 

Polycythemia 289 

Polycythemia  with  Chronic  Cyanosis 289 

Anemia 289 

Primary  or  Essential  Anemia 290 

Chlorosis  ............  292 

Secondary  Anemia 294 

Leukemia 295 

Splenomyelogenous  Leukemia 297 

Lymphatic  Leukemia     . 294 

Pseudoleukemia 299 

Purpura •        .301 

Hemophilia 304 

Hemorrhagic  Diseases  of  the  New-born 305 

Scurvy 306 

Scurvy  in  Infants 308 


X  CONTENTS 

PAGE 

Status  Lymphaticus 310 

Diseases  of  the  Suprarenal  Bodies  .        .        '. 310 

Addison's  Disease 310 

Diseases  of  the  Spleen .        .        .        .313 

Diseases  of  the  Thyroid  Gland -315 

Goiter 316 

Exophthalmic  Goiter 317 

Myxedema        . 320 

Diseases  of  the  Thymus  Gland         .        . 321 

SECTION  IV. 
Diseases  of  the  Circulatory  System  and  Mediastinum. 

Diseases  of  the  Pericardium 324 

Diseases  of  the  Heart 324 

Endocarditis 329 

Simple  Acute  Endocarditis .329 

Malignant  or  Ulcerative  Endocarditis -331 

Chronic  Endocarditis 334 

Valvular  Heart  Disease 335 

Mitral  Incompetency 337 

Mitral  Stenosis 340 

Aortic  Incompentency 342 

Aortic  Stenosis        . 346 

Tricuspid  Insufficiency  .        .        . 347 

Tricuspid  Stenosis 347 

Pulmonary  Valve  Lesions 348 

Association  of  Valvular  Lesions 348 

Hypertrophy  of  the  Heart 351 

Dilatation  of  the  Heart .        -354 

Diseases  of  the  Myocardium 356 

Acute  Myocarditis         .        .        . 356 

Chronic  Myocarditis 357 

Aneurism  of  the  Heart 361 

Rupture  of  the  Heart 362 

New  Growths  and  Parasites  of  the  Heart 362 

Wounds  and  Foreign  Bodies  in  the  Heart     .        .        .        '.        .362 

Neuroses  of  the  Heart .  3^3 

Palpitation 363 

Arrhythmia      . 363 

Tachycardia  (Rapid  Heart) 365 

Bradycardia  (Slow  Heart) 366 


COXTENTS  xi 


PAGE 


Angina  Pectoris 3^6 

Congenital  Defects  of  the  Heart 3^9 

Diseases  of  the  Arteries       . 3^9 

Acute  Aortitis 3^9 

Arteriosclerosis 3  "9 

Aneurism 3  73 

Aneurism  of  the  Aorta 374 

Aneurism  of  Other  Vessels 37^ 

Diseases  of  the  Mediastinum 37^ 

SECTION  V. 

Diseases  of  the  Respiratory  System. 

Diseases  of  the  Nose 3^1 

Acute  Coryza 3^i 

Chronic  Nasal  Catarrh 3^^ 

Hay  Fever S°3 

Epistaxis 3<^4 

Nasal  Neuroses 3^4 

Diseases  of  the  Larynx       .        .        .        •        •        •        •        •        •        •  3^5 

Acute  Laryngitis •        •        •        •        •  3^5 

Chronic  Laryngitis       .        . 385 

Edematous  Laryngitis 38° 

Neuroses  of  the  Larynx 3°° 

Diseases  of  the  Bronchi 3^7 

Acute  Bronchitis 3^7 

Chronic  Bronchitis •        •        -3^9 

Fibrinous  Bronchitis 39^ 

Bronchiectasis 393 

Bronchial  Asthma 394 

Diseases  of  the  Lungs 397 

Hyperemia  of  the  Lungs 397 

Edema  of  the  Lungs 39^ 

Pulmonary  Hemorrhage 399 

Bronchopneumonia        .        .        .        • 4°  2 

Chronic  Interstitial  Pneumonia 4°^ 

Pneumokoniosis 4°  7 

Emphysema 4o8 

Pulmonary  Collapse 4^2 

Abscess  of  the  Lung     .        .        • 4^3 

Gangrene  of  the  Lung 4i4 

Neoplasms  of  the  Lung        . 4^5 


xii  CONTENTS 

PAGE 

Parasitic  Diseases  of  the  Lung .       .416 

Diseases  of  the  Pleura 417 

Acute  Pleurisy        .        . 417 

Purulent  Pleurisy ■  .        .420 

Chronic  Pleurisy 425 

Hydrothorax .        .426 

Pneumothorax,  Hydropneumothorax,  Pyopneumothorax         .  427 

SECTION  VI. 
Diseases  of  the  Digestive  System. 

Diseases  of  the  Mouth 430 

Stomatitis 430 

Catarrhal  Stomatitis  43  a 

Aphthous  Stomatitis 430 

Parasitic  Stomatitis 431 

Ulcerative  Stomatitis    .0 43.r 

Gangrenous  Stomatitis 432- 

Membranous  Stomatitis ,        -433 

Syphilitic  Stomatitis 433 

Mercurial  Stomatitis 433 

La  Perleche .  434 

Riga's  Disease 434 

Ludwig's  Angina 434 

Diseases  of  the  Tongue 434 

Acute  and  Chronic  Glossitis       , 434 

Glossitis  Desiccans 435 

Geographical  Tongue 435 

Leukoplakia  Buccalis 435 

Macroglossia .       '.        .  435 

Hemiglossitis  .        .        .        . 435 

Epithelioma  of  the  Tongue 435 

Diseases  of  the  Salivary  Glands 435 

Supersecretion 436 

Xerostomia 436 

Inflammation  of  the  Salivary  Glands 436 

Symptomatic  Parotitis         ........  436 

Diseases  of  the  Pharynx 436 

Circulatory  Disturbances  of  the  Pharynx 436 

Neuroses  of  the  Pharynx 437 

Acute  Pharyngitis 437 

Chronic  Pharyngitis -  .        .438 


CONTENTS  xiii 

PAGE 

Retropharyngeal  Abscess 438 

Acute  Infectious  Phlegmon 438 

Diseases  of  the  Tonsils 439 

Acute  Tonsilitis 439 

Chronic  Tonsilitis 440 

Enlargement  of  the  Lingual  Tonsils 441 

Diseases  of  the  Esophagus         .        .        .        .        ,        .        .        .        .  441 

Acute  Esophagitis 441 

Chronic  Esophagitis     .        ,        .        . 442 

Stricture  of  the  Esophagus 442 

Cancer  of  the  Esophagus 443 

Neuroses  of  the  Esophagus 444 

Diseases  of  the  Stomach 445 

Examination  of  the  Stomach 446 

Acute  Gastritis 447 

Phlegmonous  or  Suppurative  Gastritis 448 

Toxic  Gastritis 449 

Chronic  Gastritis 450 

Dilatation  of  the  Stomach 455 

Peptic  Ulcer .        .        .        .        .        .459 

Cancer  of  the  Stomach        .        .        .        .        .       .       .        .       .  463 

Other  Tumors        ...        o        .......        .  468 

Hypertrophic  Stenosis 468 

Hemorrhage  of  the  Stomach 468 

Neuroses  of  the  Stomach     .        .        .        .        .        .        .        ,        .470 

Neuroses  of  Secretion ,        .470 

Neuroses  of  Motion        .        .        .        .        .       .       .        .        .472 

Neuroses  of  Sensation 474 

Diseases  of  the  Intestines 476 

Acute  Catarrhal  Enteritis 476 

Chronic  Catarrhal  Enteritis 478 

Cholera  Morbus 480 

Enteritis  in  Children .        .        .481 

Cholera  Infantum 483 

Acute  Enterocholitis 484 

Celiac  Disease 485 

Sprue  or  Psilosis 485 

Diphtheritic  Enteritis 486 

Phlegmonous  Enteritis 486 

Ulcerative  Enteritis       .        . 487 

Hemorrhage  of  the  Intestine 488 

Hemorrhagic  Infarction  of  the  Intestine 488 


xiv  CONTENTS 

PAGE 

Amyloid  Disease  of  the  Intestine 489 

Appendicitis 489 

Intestinal  Obstruction 498 

Constipation 503 

Hemorrhoids 505 

Enteroptosis 507 

Dilatation  of  the  Colon 507 

Neuroses  of  the  Intestine 508 

Enteralgia 509 

Mucous  Colitis 510 

Intestinal  Sand 511 

Diseases  of  the  Mesentery 511 

Diseases  of  the  Liver 512 

Disturbances  of  the  Hepatic  Circulation 513 

Diseases  of  the  Blood-Vessels  of  the  Liver 514 

Acute  Hepatitis 515 

Cirrhoses  of  the  Liver  . 517 

Atrophic  Cirrhosis 521 

Hypertrophic  Cirrhosis 521 

Perihepatitis 522 

Abscess  of  the  Liver 524 

Fatty  Liver     .        .        ....        . 526 

Amyloid  Liver -        •        -5^7 

Cancer  of  the  Liver      ..........  528 

Other  Tumors  of  the  Liver         .        . 5^9 

Parasites  of  the  Liver 530 

Diseases  of  the  Bile-Passages  and  Gail-Bladder 530 

Jaundice  (Icterus) 53° 

Icterus  Neonatorum 53^ 

Angiocholitis  (Cholangitis) 53 2 

Cholelithiasis  (Gall-Stones) 53 ^ 

Cancer  of  the  Gall-Bladder  and  Bile-Ducts 539 

Diseases  of  the  Pancreas 539 

Hemorrhage  of  the  Pancreas 539 

Acute  Pancreatitis -54° 

Chronic  Pancreatitis 54^ 

Fat-Necrosis 54^ 

Pancreatic  Cyst .  542 

Tumors  of  the  Pancreas 543 

Pancreatic  Calculi -543 

Diseases  of  the  Peritoneum 543 

Acute  Peritonitis    .        . -  543 


CONTENTS  XV 

PAGE 

Chronic  Peritonitis 548 

Cancer  of  the  Peritoneum 549 

Ascites 549 

SECTION  VII. 
Diseases  of  the  Kidneys. 

Anomahes  of  Form  and  Position 552 

Movable  Kidney 552 

Hyperemia  of  the  Kidney .        .        -554 

Anomahes  of  Secretion 555 

Anuria 555 

Albuminuria , 555 

Hemoglobinuria ,        ,        .        .        -557 

Hematuria       .        .        .        ., 557 

Hematoporphyrinuria .        -558 

Albumosuria 558 

Chyluria 558 

Pyuria 558 

Lithuria    .        .        .        .        . 558 

Phosphaturia 559 

Oxaluria 559 

Cystinuria -559 

Indicanuria 559 

Melanuria .      559 

Alkaptonuria  .        .        .        .        .        . 559 

Uremia : 560 

Acute  Nephritis -.        .        .        .561 

Chronic  Nephritis         . 567 

Amyloid  Kidney    .        .        . .        .572 

Pyehtis    .        .        .        .      ' 573 

Hydronephrosis     .        .        .        .        .        .        .        .        .        .        .        -575 

Nephrolithiasis 576 

Perinephric  Abscess 578 

Cystic  Kidney 579 

Tumors  of  the  Kidney 579 

SECTION  VIII. 

Co-NSTITUTIONAL    DISEASES. 

Arthritis  Deformans 581 

Chronic  Rheumatism 584 


xvi  COXTEXTS 

PAGE 

Muscular  Rheumatism 586 

Gout 587 

Rickets 593 

Diabetes • 595 

Diabetes  Insipidus 602 

Obesity 603 

SECTION  IX. 

Intoxications  and  Miscellaneous  Diseases. 


Alcoholism 605 

Morphinism 608 

Cocain  Habit 6og 

Chloral  Habit 610 

Lead-Poisoning 610 

Arsenical  Poisoning .613 

Food-Poisoning 614. 

Sunstroke 616 

Diseases  of  the  Muscles 618 

SECTIOX  X. 

Diseases  of  the  X'ervous  System. 

Diseases  of  the  Xerves 621 

Xeuritis 621 

Neuromata 625 

Diseases  of  the  Cranial  X'erves 623 

Olfactory  X'erve  and  Tract 623 

Optic  X'erve  and  Tract .        .        .        , 624 

Oculomotor  Xerve 625 

Fourth  Xerve 626 

Fifth  or  Trigeminus  X'erve 626 

Sixth  X'erve  (Xervus  Abducens) 627 

Facial  X'erve .        •       .627 

Auditory  X'erve 628 

Glossopharyngeal  X'erve 629 

Pneumogastric  (Vagus)  X'erve 6.-? 9 

Spinal  x\ccessory  X'erve 630 

Hypoglossal  X^erve 631 

Diseases  of  the  Spinal  Nerves 632 

Cervical  Plexus ^32 

Brachial  Plexus 633 


CONTENTS  xvii 

PAGE 

Lumbar  Plexus 634 

Sacral  Plexus 634 

Sciatica 634 

Diseases  of  the  Spinal  Cord  and  Meninges 635 

Spinal  Pachymeningitis 635 

Spinal  Leptomeningitis 636 

Affections  of  the  Blood-Vessels  and  Circulation  of  the  Cord    .  63  7 

Caisson  Disease .        .638 

Myelitis 639 

Compression  of  the  Spinal  Cord       .......  641 

Acute  Anterior  Poliomyelitis 642 

Acute  Ascending  Paralysis 644 

Progressive  Muscular  Atrophy 645 

Glossolabiolaryngeal  Paralysis 646 

The  Spinal  Scleroses , 647 

Posterior  Spinal  Sclerosis     .        .        .        .        .        .        .        .  647 

Primary  Lateral  Sclerosis 651 

Ataxic  Paraplegia  (Cowers) 652 

Hereditary  Ataxia 652 

Syringmyelia 653 

Tumors  of  the  Spinal  Cord 654 

Malformations  of  the  Spinal  Cord 655 

Diseases  of  the  Brain  and  its  Meninges 656 

Diseases  of  the  Meninges 656 

Affections  of  the  Blood-Vessels  and  Circulation  of  the  Brain  .  658 

Cerebral  Hemorrhage 661 

Cerebral  Paralyses  of  Childhood      .        ...        .        .        ,  666 

Acute  Encephalitis         .        . 667 

Suppurative  Encephalitis .        .        .667 

Chronic  Meningoencephalitis 669 

Sclerosis  of  the  Brain ..        .        .671 

Tumors  and  Cysts  of  the  Brain 672 

Aphasia 674 

Hydrocephalus 675 

Functional  Nervous  Diseases 677 

Acute  Delirium 677 

Paralysis  Agitans ,        .        .        .        ,678 

Other  Tremors 679 

Acute  Chorea 680 

Choreoid  Affections       .        . 682 

Convulsions  of  Children 682 

Epilepsy ■ 684 


xviii  CONTENTS 

PAGE 

Tetany -      .        .       .  688 

Migraine ^ 689 

Neuralgia 690 

Hysteria  .        .       .        .        .        . 693 

Neurasthenia 696 

Occupational  Neuroses 699 

Traumatic  Neuroses 700 

Functional  Paralyses 701 

Periodical  Paralysis 701 

Astasia — Abasia 701 

Vasomotor  and  Trophic  Disorders 701 

Raynaud's  Disease 701 

Erythromelalgia .  703 

Angioneurotic  Edema 703 

Facial  Hemiatrophy      . 704 

Scleroderma .  704 

Acromegaly 705 

Rare  Vasomotor  Affections 706 


PART  III. 

Clinical   Methods  of  Examination. 

Examination  of  the  Blood 711 

The  Blood-Count 711 

Widal  Serum  Test 717 

Specific  Gravity  of  the  Blood    .        .        .        .        .       .       .        .717 

Bacteriological  Examination  of  the  Blood    .        .        .       .        .     718 

Tests  for  Blood      ...» .      718 

Examination  of  Stomach-Contents 719 

Qualitative  Tests .        .        .720 

Quantitative  Tests •        .722 

Microscopic  Examination -7^3 

Examination  of  Stomach-Washings .724 

Examination  of  Vomitus 7^4 

Examination  of  Intestinal  Discharges 724 

Disinfection  of  Dejecta 7^7 

Examination  of  the  Urine •        •        •      T^l 

Tests  for  Normal  Ingredients .728 

Abnormal  Constituents       . 73° 


CONTENTS  xix 

PAGE 

Drugs  in  the  Urine .  734 

Urinary  Sediments 736 

Urinary  Casts 738 

Animal  Parasites 739 

Vegetable  Parasites 740 

Cryoscopy 741 

Bacteriological  Methods 741 

Examination  of  Sputum 748 


PART    I. 

THE    PRINCIPLES    OF    MEDICINE. 


A  TEXT-BOOK 

ON 

THE    PRACTICE  OF   MEDICINE. 


Disease  is  an  abnormal  state  of  the  body,  a  perversion  or  interruption 
of  the  function  of  any  organ  or  tissue,  with  or  without  corresponding 
structural  change. 

The  disturbance  must  be  more  or  less  continuous.  A  temporary  al- 
teration of  function,  due  to  a  transient  cause,  may  be  strictly  physio- 
logical and  it  may  result  in  the  removal  of  some  harmful  agent  or 
substance  and  thus  prevent  more  permanent  disturbance.  The  rapid 
respiration  and  quickened  heart's  action  which  follow  active  exercise, 
for  example,  do  not  denote  disease,  for  experience  has  shown  that  they 
are  normal  and  necessary  to  the  vitality  of  the  tissues ;  but  if  a  similar 
acceleration  of  these  functions  habitually  follow  slight  exertion,  it  is  to 
be  regarded  as  pathological,  an  indication  of  disease. 

In  many  instances  disease  is  first  manifested  by  either  an  increase 
or  a  diminution  of  functional  activity,  on  the  order  of  that  just 
referred  to,  or  there  may  be  an  evident  loss  of  harmony  between  two  or 
more  physiological  processes.  As  a  rule  abnormal  function  denotes  an 
impairment  of  structural  integrity,  although  we  may  not  be  able  to 
discover  it.  But  an  interruption  or  perversion  of  function  may  undoubt- 
edly occur  in  an  organ  free  from  structural  change.  Our  knowledge  of 
the  pathological  changes  which  underlie  the  manifestations  of  disease 
is  becoming  daily  more  exact,  but  it  does  not  yet  enable  us  to  exclude 
from  our  classification  all  those  affections  which  have  been  regarded  as 
functional. 

In  a  systematic  study  of  medicine,  the  diseases  are  studied  as  indi- 
viduals, as  entities.  The  first  aim  of  the  student  is  to  become  able  to 
recognize  each  disease  by  its  cause,  the  structural  changes  and  clinical 
manifestations  in  which  it  differs  from  all  others.  In  some  affections 
it  is  one  of  these  features,  in  some  another,  that  is  most  important  to 
its  recognition.  But  Medicine  is  not  yet  an  exact  science,  and  it  is  prob- 
able that  many  affections  which  we  now  regard  as  distinct  diseases 
will,  in  the  course  of  time,  be  found  capable  of  more  accurate  subdivi- 
sion. The  acute  exanthemata  as  we  know  them  were  at  one  time  re- 
garded as  varieties  of  a  single  disease,  and  at  the  time  this  is  written 
it  is  a  matter  of  dispute  whether  or  not  there  is  yet  a  "  Fourth  disease" 
in  the  measles  and  scarlatina  group.  In  the  study  of  individual  diseases, 
again,  we  must  often  take  into  consideration  two  or  more  subvarieties 
of  the  same  affection,  owing  to  differences  in  the  symptomatology  of  dif- 
ferent cases,  as  in   malaria  and  rheumatism.     And  it  is  not  improbable 


4  PRACTICE  OF  MEDICINE 

that    many    of  these  will,   in  the  future,   be  resolved  into  independent 
affections  when  their  causes  become  more  definitely  known. 

CLASSIFICATION  OF  DISEASES  (NOSOLOGY). 

It  is  customary  to  classify  diseases  according-  to  their  origin,  clinical 
course,  duration,  and  other  features.  No  entirely  satisfactory  classifi- 
cation has  ever  been  devised,  however,  and  the  chief  object  in  presenting 
the  following  brief  classification  is  to  familiarize  the  student  with  the 
terms  that  are  generally  employed  : 

I.  Every  disease  may  be  classed  as  general  or  local  in  character. 
(i)  A  general  disease  involves  the  entire  system.  The  class  embraces 
(a)  most  of  the  acute  infections,  as  typhoid  fever,  measles,  smallpox, 
(Ji)  the  so-called  constitutional  or  blood  diseases,  as  pernicious  anemia, 
g-out,  and  scurvy,  and  (r)  the  intoxications  by  lead,  arsenic,  opium,  and 
other  poisons. 

(2)  Local  diseases  are  those  which  affect  particular  organs  or  tissues. 
They  may  be  subdivided  into  (<;?)  organic,  or  structural,  embracing  af- 
fections of  the  brain,  heart,  lungs,  skin,  or  other  organs  or  tissues,  and 
(J))  functional  disorders,  in  which  the  action  of  an  organ  is  impaired 
without  discoverable  structural  lesion.  The  number  of  functional  disorders 
has  been  greatly  reduced  in  recent  years  by  the  discovery  that  many 
which  were  formerly  so  regarded  depend  upon  lesions  more  or  less  remote 
from  the  part  in  which  the  clinical  manifestations  appear.  And,  since 
the  disturbing  influence  often  originates  in  the  nervous  system,  or  is  at 
least  conveyed  through  the  nervous  system  to  the  point  of  its  expres- 
sion, these  affections  have  been  grouped  under  the  head  of  reflex  ?ieu- 
roses.  It  should  be  remembered  also  that  many  of  the  general  diseases 
have  their  local  expressions  in  some  organ  or  tissue,  and  that  a  pri- 
marily local  disease  may  lead  to  general  disturbance  of  the  system. 

II.  A  disease  may  be  acute,  subacute,  or  chronic,  (i)  It  is  acute 
when  it  is  severe  in  character,  of  short  duration,  and  runs  a  rapid  course, 
a  feature  of  the  acute  exanthemata,  (2)  subacute  when  these  features 
are  less  marked  as  in  some  cases  of  rheumatism,  and  (3)  chronic  when 
of  slow  progress  and  long  duration,  as  in  tuberculosis  and  syphilis. 
The  distinction  between  acute  and  subacute  is  entirely  one  of  degree  and 
not  always  clearly  defined. 

III.  The  course  of  a  disease  may  be  paroxysmal,  periodic,  continuous, 
or  recsurrent.  (i)  K  paroxysmal  disease  is  characterized  by  sudden  ex- 
acerbations of  severity,  or  it  manifests  itself  in  sudden,  explosive  seiz- 
ures, as  in  epilepsy  and  some  forms  of  neuralgia.  (2)  h.pe7-iodic  disease 
is  one  which  occurs  with  regularity  at  definite  intervals  of  time,  as  ter- 
tian and  quartan  malaria.  (3)  The  term  continuous  is  applied  to  some 
fevers  to  describe  their  uninterrupted  course,  and  (4)  recurrent,  to  desig- 
nate a  disease  that  returns  during  or  soon  after  apparent  convalescence, 
as  relapsing  fever.  The  term  recrudescence  is  applied  when  the  symp- 
toms unexpectedly  return  after  a  remission  and  when  their  return  is 
due  to  a  revivifying  of  the  original  infection  or  to  a  reinfection  by  the 
same  organism,  as  occasionally  occurs  in  typhoid  fever. 

IV.  Diseases  are  further  classified  as  sporadic,  endemic,  epidemic,  and 
pandemic  in  the  extent  of  their  prevalence.  (i)  A  sporadic  disease 
is  one  that  may  occur  in  any  place  at  any  time;   the  term  is  employed 


THE  CAUSES    OF  DISEASE  5 

chiefly  to  distinguish  such  affections  as  sporadic  cholera  from  similar 
affections  of  an  epidemic  character.  (2)  An  endemic  distaiSe  is  one  which, 
owing  to  some  local  influence,  is  more  prevalent  in  a  certain  locality 
than  elsewhere,  as  is  usual  with  malaria  and  yellow  fever.  (3)  An 
epidemic  disease  attacks  simultaneously  or  in  quick  succession  a  large 
number  of  individuals  in  the  same  locality,  or  spreads  rapidly  over  a 
large  territory,  as  is  frequently  the  case  with  smallpox,  scarlatina,  and 
measles,  and  (4)  a.  pa7idci?iic  is  one  that  attacks  almost  without  excep- 
tion the  entire  population  of  a  city  or  country,  as  occurs  in  influenza, 
cholera,  and  bubonic  plague. 

V.  With  reference  to  their  mode  of  origin,  diseases  are  hereditary, 
congenital,  or  acquired.  They  are  (i)  hereditary  when  communicated 
to  an  individual  by  his  progenitors.  In  most  instances  it  is  only  a  sus- 
ceptibility to  the  disease  that  is  thus  handed  down.  (2)  A  congenital 
disease  either  exists  or  originates  at  the  time  of  birth,  and  (3)  an 
acquired  disease  is  one  that  develops  in  after-life,  independently  of 
either  hereditary  or  congenital  influences. 

VI.  In  their  causation,  diseases  may  be  infectious,  parasitic,  or  toxic. 
(i)  The  term  infectious  is  now  generally  limited  to  diseases  that  are 
more  or  less  definitely  known  to  owe  their  origin  to  the  presence  of 
bacteria.  Their  number  is  continually  being  added  to  as  new  discoveries 
are  made  in  bacteriology.  The  class  is  sometimes  subdivided  into  («•) 
contagious  and  (/;)  non-contagious,  to  denote  that  the  disease  can  or 
cannot  be  communicated  to  a  health}^  person  who  comes  into  contact 
with  one  who  is  infected.  The  contagion  is  said  to  be  mediate  when  it 
can  be  carried  through  the  medium  of  fomites,  such  articles  as  clothing, 
furniture,  draperies;  or  immediate  when  actual  contact  is  necessary. 
(2)  The  ttXTsx  parasitic  i^s,  generally  restricted  in  its  applica^tion  to  the 
diseases  due  to  the  presence  of  animal  parasites.  (3)  A  toxic  disease, 
or  intoxication,  is  caused  by  a  chemical  poison.  The  poison  may  be 
((?)  organic,  including  ptomains  and  leucomains,  or  (Ji)  inorganic, 
phosphorus,  arsenic,  lead,  etc. 

VII.  Such  terms  as  primary,  secondary,  and  specific  are  sometimes 
employed.  An  affection  is  prima?y,  or  essential,  when  it  develops  spon- 
taneously or  independently  of  any  other  affection.  A  specific  disease  is 
one  that  is  due  to  a  definitely  recognized  virus  or  microbe  and  runs  a 
definite  course. 

THE   CAUSES  OF  DISEASE  (ETIOLOGY). 

Any  influence  that  is  capable  of  impairing  the  integrity  of  an  organ 
or  tissue  or  of  disturbing  its  function  may  become  a  cause  of  dis- 
ease. In  the  production  of  most  affections  a  succession  or  combina- 
tion of  such  influences  is  operative. 

The  causes  of  disease  may  be  divided  into  two  classes,  predisposing 
or  remote,  and  exciting  or  determinate. 

I.  A  predisposing  cause  is  one  which  prepares  the  individual  for  the 
action  of  the  exciting  cause  by  rendering  him  susceptible  to  its  action. 
It  is  owing  to  some  predisposing  influence  that  one  individual  falls  vic- 
tim to  a  disease  from  which  another  individual  similarly  exposed  escapes. 
Predisposition  may  be  either  inherited  or  acquired.  Among  the  influences 
that  are  recognized  as  the  most  common  predisposing  causes  are  {ji^ 


6  PIL^CTICE  OF  MEDICINE 

age,  Qf)  sex,  (^)  race,  (^/)  occupation,  (^)  diet,  ( /")  habits  of  life,  (^) 
climate,  and  (/;)  previous  illness. 

2.  The  most  prominent  exciting  causes  are  (c?)  infection  by  bacteria, 
(<^)  autointoxication,  (r)  invasion  by  animal  parasites,  and  (^d^  poisons. 
Injury,  exposure  to  heat  or  cold,  improper  food  or  drink,  and  many 
other  influences  may  act  as  either  predisposing  or  exciting  causes.  All 
these  influences  will  be  considered  in  connection  with  the  individual 
diseases. 

Infection  is  the  condition  produced  in  the  body  by  the  entrance  and 
propagation  of  pathogenic  bacteria.  It  is  considered  under  the  head 
of  Bacteriology,  on  page  37. 

Autointoxication,  or  self-poisoning,  is  a  term  applied  to  a  class  of 
diseases  not  yet  fully  identified,  which  result  from  the  accumulation  in 
the  system  of  the  products  of  metabolism  or  those  of  bacteriological 
decomposition.  It  results  in  some  instances  from  processes  which  are  in 
themselves  normal,  the  poisonous  effect  arising  from  a  disturbance  of 
the  relation  between  production  and  elimination.  There  may  be  («;) 
overproduction  alone,  or  (/^)  only  deficient  elimination;  or  these  con- 
ditions may  be  combined.  We  are  indebted  chiefly  to  Bouchard  for  the 
knowledge  we  possess  of  the  conditions. 

1.  Leucomains. — The  products  of  metabolism  have  been  named 
leucomains.  They  are  believed  to  be  derived  from  the  nuclein  in  the 
nuclei  of  the  cells.  The  best  known  members  of  the  class  are :  adenin, 
creatin,  creatinin,  guanin,  xanthin,  hypoxanthin,  and  paraxanthin. 
Vaughan  and  Novy  have  found  them  nontoxic,  except  paraxanthin, 
which  has  been  found  only  in  the  urine.  To  their  presence  are,  neverthe- 
less, attributed  many  disturbances,  especially  on  the  part  of  the  nervous 
system.  Urea  is  closely  related  to  these  bodies  in  its  origin  and  sup- 
posed action. 

2.  Ptoma/ns. — The  decomposition  of  proteids  by  the  action  of  bac- 
teria gives  rise  to  another  class  of  poisons,  alkaline  bases,  known  as 
ptomains.  Among  those  which  have  been  isolated  are  cadaverin,  putres- 
cin,  neuridin,.saprin,  and  the  aromatic  group,  indol,  phenol,  and  cresol; 
there  are  many  others  which  have  been  produced  for  the  most  part 
through  experimentation.  They  may  enter  the  body  preformed,  in  food 
that  has  previously  undergone  putrefaction,  as  when  partially  decomposed 
meat  or  fish  is  ingested,  or  they  may  be  formed  by  the  decomposi- 
tion of  proteids  in  the  intestine,  through  the  action  of  bacteria. 

3.  Acid  Intoxication. — Another  form,  of  intoxication  is  due  to  the 
metabolic  production  of  such  acid  bodies  as  uric,  lactic,  sarcolactic, 
sulphuric,  phosphoric,  and  fatty  acids,  especially  as  a  result  of  fever, 
inanition,  anemia,  acute  yellow  atrophy  of  the  liver,  diabetes,  and 
cancer.  The  production  of  these  bodies  is  attributed  both  to  decom- 
position of  proteids  and  to  defective  oxidation.  Their  presence  in  ab- 
normal quantity  is  supposed  to  be  indicated  (^?)  by  disturbances  of 
the  nervous  system,  mental  dulness,  and  especially  the  coma  which  so 
often  announces  approaching  dissolution;  (/;)  by  the  production  of  a 
cachexia ;  (r)  but  especially  by  excessive  elimination  through  the 
kidneys. 

4.  The  retention  of  bile  salts  and  their  entrance  into  the  circu- 
lation   produce   a   form    of   autointoxication,   cholcmia,   which    is    mani- 


PATHOLOGY  7 

fested  by  the  characteristic  discoloration  of  the  skin  and  other  tissues, 
accompanied  with  various  systemic  disturbances.  The  remains  of  dis- 
organized blood  and  broken-down  tissues,  the  results  of  injury,  may 
be  absorbed  and  cause  intoxication,  often  manifested  in  the  so-called 
aseptic  fev  67'. 

Many  of  the  substances  which  are  capable  of  producing  autointoxi- 
cation are  always  present  in  the  body,  and  we  are  not  fully  acquainted 
with  the  influences  that  cause  them  to  be  absorbed  into  the  blood 
only  at  certain  times.  It  has  recently  been  attributed  to  a  change  in 
the  osmotic  pressure  of  the  blood. 

Our  knowledge  of  the  autointoxications  is  not  yet  so  complete  as 
to  enable  us  in  all  cases  to  refer  a  group  of  symptoms  to  its  specific 
cause.  The  most  prominent  manifestations  are  generally  seen  in  the 
derangement  of  nervous  functions,  frequently  accompanied  with  disturb- 
ances of  the  gastrointestinal  tract  and  changes  in  the  composition  of  the 
urine.  Headache,  drowsiness,  anorexia  or  vomiting,  hebetude  or  coma, 
sometimes  convulsions,  characterize  most  of  the  cases.  The  symptoms 
are  often  erroneously  assumed  to  be  due  to  uremia.  Bouchard  regards 
autointoxication  as  a  frequent  cause  of  trophic  disturbances  in  the 
muscles,  joints,  and  other  tissues. 

Animal  Parasites. — A  large  group  of  diseases  arises  from  the  pres- 
ence of  animal  parasites  within  the  body.  The  lowest  class  of  these 
parasites  embraces  the  protozoa,  to  which  belong  the  parasites  of 
malaria  and  dysentery;  the  psorospertns,  known  also  as  cytozoa  on 
account  of  their  being  found  within  cells,  and  the  coccidia,  sometimes 
classed  with  the  psorosperms.  The  best  example  for  study  is  the  coc- 
cidium  oviforme,  found  in  small  saccular  dilatations  of  the  bile-ducts 
of  rabbits.  Different  parasites  of  this  class  have  been  described  by  vari- 
ous investigators,  but  not  fully  demonstrated,  as  the  causes  of  carcinoma, 
epithelioma,  sarcoma,  measles,  scarlet  fever,  pernicious  anemia,  and  other 
diseases;  and  others  are  occasionally  associated  with  skin  diseases  or 
intestinal  disturbances. 

Of  the  more  highly  organized  animal  parasites  there  are  two  classes, 
namely,  the  epizoa  and  the  entozoa.  The  former  exist  only  in  the  skin 
or  upon  its  surface ;  the  latter,  about  fifty  in  number,  penetrate  to  the 
deeper  parts  of  the  body. 

The  entozoa  are  more  familiar  to  us  as  worms.  They  may  be  divided 
into  three  classes :  cestodes,  nematodes,  and  trematodes.  (a)  The  ces- 
todes  are  the  tapeworms.  (Ji)  The  nematodes  are  round  or  threadlike 
worms,  including  the  lumbricoids,  filiaricE,  and  trichina,  (r)  The  tre- 
matodes constitute  a  class  to  which  belong  the  liver-flukes.  Some  of  the 
entozoa  enter  the  body  as  mature  worms,  some  in  a  larval  state,  while 
others  develop  within  the  body  from  eggs  that  have  been  taken  in  with 
food  or  drink.  Their  relation  to  the  production  of  diseases  is  further 
considered  under  the  diseases  attributed  to  them. 

PATHOLOGY. 

Disturbances  of  Nutrition  and  Metabolism.— The  term  metaboHsm  is 
applied  to  the  processes  constantly  going  on  in  the  body  through  which 
(i)  the  tissues  appropriate  the  nutriment  that  is  brought  to  them  in 


8  PRACTICE  OF  MEDICINE 

the  blood,  and  (2)  prepare  the  protoplasm  of  the  cells  for  special  uses 
or  for  excretion.  It  is  in  the  first  instance  a  constructive  process 
(anabolism)  and  in  the  second  a  destructive  one  (katabolism).  So 
long  as  these  two  processes  maintain  a  proper  balance,  the  body  re- 
mains in  a  normal  state  of  nutrition.  The  source  of  supply  is  the  food. 
In  order  to  fully  replace  the  losses  of  heat  and  energy  occasioned  by  all 
the  vital  activities,  the  food  ingested  must  be  not  only  sufficient  in 
quantity  and  suitable  in  kind,  but  its  essential  elements,  proteids,  fats, 
and  carbohydrates,  must  be  appropriated  in  sufficient  amount. 

Excessive  Nutrition. — Oversupply  of  food  does  not  necessarily  pro- 
duce excessive  nutrition.  The  appropriation  depends  in  part  upon  the 
character  of  the  food,  in  part  upon  such  extrinsic  influence  as  exercise, 
but  to  a  greater  extent  upon  individual  peculiarities  of  the  metabolic 
processes.  In  many  cases  oversupply  leads  to  only  an  excessive 
retention  or  discharge  of  such  end-products  of  metabolism  as  urea. 
The  overappropriation  of  nourishment  seen  in  obesity  is  derived  in 
part  from  the  fat  ingested  with  the  food,  but  more  particularly  from  the 
carbohydrates.  It  is  very  often  out  of  proportion  to  the  quantity  of 
these  substances  ingested.  Obesity  is  therefore  regarded,  in  most  in- 
stances, as  a  result  of  abnormal  metabolism  the  nature  of  which  has 
not  been  fully  determined.  By  some  investigators  it  is  regarded 
as  a  result  of  deficient  oxidation,  especially  when  it  is  associated  mth 
anemia. 

Diminished  Nutrition. — A  deficient  supply  of  food,  or  an  inability 
of  the  system  to  prepare  and  appropriate  that  received,  results  in  a 
condition  of  inanition  which  may  be  slight  or  so  extreme  as  to  result  in 
death.  The  first  indications  of  inanition  are  generally  a  loss  of  body 
weight  and  a  diminution  of  the  energy  of  the  various  organs.  The  loss 
of  weight  results  from  the  consumption  by  the  organism  itself,  first  of  the 
fat  and  later  of  other  tissues.  The  body  appropriates  its  own  tissues 
for  food.  The  tissues  are  said  to  undergo  atrophy.  Impairment  of 
the  nutrition  of  a  single  organ  or  tissue  from  any  cause  leads  to  local 
atrophy,  as  in  the  wasting  of  a  paralyzed  member.  General  lack  of 
nutrition  is  seen  in  many  pathological  processes,  notably  in  fevers  and 
in  infectious  diseases.  When  the  result  of  chronic  disease  or  of  the 
growth  of  a  tumor,  the  wasting  is  called  ■marasmii.s  or  cachexia;  when  the 
result  of  toxic  matter  carried  in  the  blood,  it  is  sometimes  spoken  of 
as  a  dyscrasia. 

Generalization  of  Disease. — An  organ  often  becomes  diseased  as  a 
result  of  a  morbid  process  in  another  organ.  Some  diseases  are  definitely 
local  in  character  and  produce  little  or  no  disturbance  in  other  parts 
of  the  body ;  while  others  begin  as  local  processes  and  rapidly  become 
generalized.  The  generalization  of  the  infectious  diseases  depends  in  part 
upon  the  action  of  the  toxins  upon  the  nervous  system  and  in  part 
upon  their  affinity  for  particular  cells.  A  similar  generalization  occurs 
in  many  noninfectious  diseases,  especially  in  the  autointoxications, 
producing,  as  prominent  manifestations,  elevation  of  temperature,  loss 
of  strength,  and  emaciation. 

An  impairment  of  the  function  of  one  organ  sometimes  exercises  an 
important  influence  upon  other  organs.  At  first  functional,  such  dis- 
turbances may  become  organic.    The  original  impairment  of  function  in 


PATHOLOGY  9 

some  instances  throws  toxic  matter  into  the  circulation  which  acts  in- 
juriously upon  the  parenchyma  cells  of  other  organs,  causing  more  or 
less  pronounced  degenerative  changes  in  them.  Or  a  similar  result  may 
follow  the  loss  of  an  agent  normally  secreted  by  the  organ  which  be- 
comes the  seat  of  a  morbid  process.  The  heart,  voluntary  muscles,  glands, 
and  kidneys  are  especially  liable  to  become  the  seat  of  such  degenerations, 
the  kidneys  more  than  other  organs,  perhaps,  because  they  are  called 
upon  to  remove  from  the  system  a  greater  part  of  the  poisonous 
materials  resulting  from  the  disease  processes. 

The  blood  serves  as  the  carrier  of  the  toxic  matters  resulting  from 
disease,  as  well  as  of  those  producing  it,  and  consequently  undergoes  im- 
portant changes  in  composition  and  quantity.  These  changes  diminish 
the  supply  of  nutrition  to  the  organs  and  tissues  and  therefore  consti- 
tute another  factor  in  the  generalization  of  the  morbid  processes. 

Changes  in  the  Blood  and  Circulation.— TAe  B/ood.— The  quantity 
and  composition  of  the  blood  remain  remarkably  constant  during 
health,  despite  the  many  influences  to  which  it  is  exposed.  Slight 
changes  take  place  from  hour  to  hour,  it  is  true,  with  the  ingestion 
of  food  and  drink,  and  the  circulation  is  made  the  avenue  of  the  effete 
products  of  metabolism  on  their  way  to  elimination. 

Plethora,  or  overabundance  of  blood,  formerly  regarded  as  of  much 
importance,  is  believed  to  be  unusual  and  of  short  duration.  In  the 
oligemia,  or  reduction  of  quantity,  which  results  from  hemorrhage,  the 
loss  is  quickly  compensated  for  by  the  contraction  of  the  blood-vessels, 
the  appropriation  of  fluids  from  the  tissues,  and  generally  by  an  increased 
supply  of  water  that  is  drunk  in  order  to  quench  the  imperative 
thirst. 

An  abnormal  increase  of  the  water  in  the  blood  gives  rise  to  hydremia, 
a  condition  which  is  overcome  by  a  rapid  formation  of  new  blood-cells 
and  the  elimination  of  the  water  through  the  secretions.  Hydremia  is 
believed  to  occur  in  some  conditions  of  anemia.  The  opposite  condition, 
anhydremia,  in  which  the  water  of  the  blood  is  deficient,  is  produced  by 
a  profuse  discharge  of  water  through  the  bowels  in  cholera,  through  the 
kidneys  in  diabetes,  or  by  excessive  sweating. 

The  diseases  involving  changes  in  the  erythrocytes  are  considered 
under  the  Diseases  of  the  Blood. 

Leucocytosis  (hyperleucocytosis)  is  a  recognized  feature  of  an  in- 
creasingly large  number  of  diseased  conditions.  When  moderate,  it  is 
sometimes  regarded  as  physiological.  The  number  of  leucocytes  in  the 
cubic  millimeter  of  normal  blood  varies  from  4,000  to  10,000.  In- 
crease or  decrease  beyond  these  limits  indicates  a  pathological  condition. 
Diminution  of  the  number  is  termed  hypoleucocytosis.  Leucocytosis 
may  be  active  or  passive.  The  best  example  of  the  former  is  seen  in 
phagocytosis  (p.  40).  The  principal  causes  of  leucocytosis  are :  ((/) 
Infection  and  the  resultant  toxemia,  Q))  disease  of  the  blood-forming 
organs,  (<:)  malignant  disease,  (/^)  hemorrhage,  and  (.?)  the  action  of 
certain  drugs.  It  sometimes  develops  also  immediately  before  death, 
although  absent  during  the  course  of  the  disease. 

As  a  result  of  toxic  influences,  leucocytosis  occurs  in  probably  all  the 
acute  infectious  diseases,  except  typhoid  fever,  uncomplicated  tubercu- 
losis, measles,  and  perhaps  influenza.    As  an  autointoxication  it  is  seen 


lo  PRACTICE  OF  MEDICINE 

in  acute  disorders  of  digestion,  gout,  cirrhosis  and  acute  yellow  atrophy 
of  the  liver,  acute  and  chronic  nephritis,  and  hydronephrosis.  In  both 
these  classes  of  cases  it  is  an  active  process  having  for  its  object  the 
protection  of  the  system. 

Hypoleiicocytosis  is  always  pathological  and  met  with  :  («)  In  the 
infections,  typhoid  fever,  measles,  tuberculosis,  and  influenza;  (^)  under 
certain  conditions,  in  infections  ordinarily  attended  with  leucocytosis; 
(t)  in  some  cases  of  leukemia  and  pseudoleukemia;  and  (^)  as  a  result 
of  the  action  of  certain  drugs.  The  development  of  a  mixed  infection 
in  these  cases  immediately  induces  a  hyperleucocytosis. 

The  Circulation. — The  circulation  of  the  blood  is  maintained  almost 
entirely  by  the  rhythmical  contractions  of  the  heart;  the  uniformity 
of  blood  pressure,  by  the  elasticity  of  the  blood-vessels.  The  pressure 
in  the  pulmonary  artery  is  never  so  strong  as  that  in  the  aorta.  The 
normal  relation  between  the  heart's  action  and  the  blood  pressure  is 
under  the  supervision  of  the  nervous  system,  to  a  great  extent  under 
that  of  the  ganglia  situated  in  the  heart  itself. 

Deficient  Blood  F?-essu7'e. — The  systemic  blood  pressure  is  diminished 
by  every  impairment  of  the  integrity  of  the  heart,  whether  involving 
its  muscle,  its  valves,  or  its  ganglia,  unless  the  defect  is  fully  compen- 
sated for  by  increased  force  of  action.  The  heart  muscle  may  be  im- 
paired by  fatty  and  other  degenerations  resulting  from  (a)  long-con- 
tinued fevers,  (Z-)  the  presence  of  poisonous  matter  in  the  blood,  or 
(r)  such  impairment  of  nutrition  as  that  caused  by  sclerosis  of  the 
coronary  arteries.  The  action  of  the  heart  is  interfered  with  also  by 
((^z)  adhesions  which  bind  the  organ  to  adjacent  structures,  Qf)  an 
accumulation  of  fat  or  fluid  in  the  pericardium,  (<:)  the  pressure  of 
tumors  above  or  below  the  diaphragm,  as  well  as  by  (^d^  hydrothorax 
or  ascites. 

Deficient  blood  pressure  in  the  arterial  system,  due  to  defective  car- 
diac action,  is  generally  attended  with  an  increased  accumulation  of 
blood  in  the  veins ;  a  venous  stasis,  passive  hyperemia,  or  engorgement. 
Incompetency  of  the  mitral  valve,  for  example,  permitting  the  regurgi- 
tation of  the  blood  into  the  left  auricle,  produces  engorgement  of  the 
pulmonary  circulation.  The  increased  action  of  the  right  ventricle  pre- 
vents for  a  time  a  further  retardation  of  the  circulation.  But  when,  as 
sooner  or  later  happens,  the  right  heart  loses  its  ability  to  compensate, 
the  engorgement  becomes  general.  When  the  right  side  of  the  heart  is 
primarily  affected,  passive  hyperemia  rapidly  develops  in  all  parts  of 
the  body. 

Weakness  of  the  circulation,  aided  by  gravitation  of  the  blood,  es- 
pecially after  long  confinement  to  bed  in  chronic  febrile  diseases,  often 
leads  to  such  local  disturbances  as  hypostatic  congestion  of  the  lungs 
or  an  accumulation  of  blood  in  the  vessels  of  the  more  dependent  por- 
tions of  the  body.  Extravasations  occur  in  the  same  manner  and  are 
seen  as  ecchymoses  in  the  skin.  They  are  often  followed  by  edema  and 
sloughing,  as  in  the  formation  of  bedsores. 

Increased  blood  pressure  is  generally  transitory,  like  that  which  results 
fi-om  overaction  of  the  heart  during  violent  muscular  exercise  or  ner- 
vous excitement.  It  may  result  also  from  the  presence  of  toxic  sub- 
stances in  the  blood,   but  it  then  gives  place,   as  a  rule,  to  weakness. 


PATHOLOGY  n 

Overaction  from  violent  effort  may  lead  to  hemorrhage,  especially  when 
there  is  a  defect  in  the  blood-vessel  walls.  The  increased  action  of  the 
heart  occasioned  by  an  effort  to  compensate  for  abnormal  conditions 
within  itself,  or  by  changes  in  the  blood-vessels,  as  in  general  arterio- 
sclerosis, leads  first  to  hypertrophy  of  the  ventricles,  but  later  to  de- 
generation of  its  muscles,  with  permanent  dilatation  of  its  chambers. 
Many  disturbances  of  the  heart's  action  and  of  the  circulation  are  to 
be  attributed  to  the  influence  of  the  nervous  system  expressed  through 
the  vasomotor  nerves. 

Local  Anemia. — When  from  any  cause  the  blood  supply  of  a  part 
is  diminished  or  completely  cut  off,  a  local  anemia,  or  ischemia,  is  pro- 
duced. This  varies  from  a  very  slight  deficiency  to  complete  absence 
of  blood.  When  an  artery  is  suddenly  obstructed,  as  by  an  embolus, 
this  anemic  condition  is  immediately  produced.  This  is  true  especially 
of  those  organs  whose  circulation  is  supplied  through  terminal  or  end 
arteries,  where  an  immediate  relief  of  the  anemia  through  anastomotic 
circulation  is  impossible.  Here  the  anemia  becomes  the  first  step  in 
the  development  of  an  infarction.  The  term  ischemia  is  often  restricted 
in  its  application  to  anemia  caused  by  arrest  of  the  arterial  blood 
entering  the  part.  A  collateral  anei7iia  is  the  condition  produced  when 
the  blood  is  withdrawn  from  a  region  to  meet  the  demand  for  it  in  an 
adjacent  area  which  is  in  a  state  of  congestion. 

Causes. — Local  anemia  is  caused  for  the  most  part  by  («;)  disease 
of  the  walls  of  the  vessels  supplying  the  area,  Qi)  compression  of  the 
vessel  by  cicatricial  tissue,  tumors,  or  accumulated  fluids,  (r)  inflamma- 
tory processes  around  it,  or  (^)  by  influences  operating  upon  it  through 
the  nervous  system.  The  most  important  of  the  diseases  of  the  vessel 
walls  capable  of  operating  in  this  manner  are  acute  inflamma.tion,  sclero- 
sis, atheroma,  syphilis,  and  amyloid  disease.  Thrombosis  and  embolism 
produce  anemia  of  the  part  supplied  by  the  obstructed  vessel.  The  ap- 
plication of  cold  to  a  part  renders  it  relatively  anemic  by  constricting 
its  vessels;  freezing  produces  absolute  anemia.  Anemia  resulting  from 
hemorrhage  is, most  profound  in  the  extremities.  Among  the  instances 
of  local  anemia  produced  through  the  action  of  the  nervous  system  may 
be  mentioned  the  early  symptom  of  Raynaud's  disease,  the  blanching 
often  seen  in  a  part  affected  with  neuralgia,  and  the  pallor  of  the  face 
accompanying  nausea  or  fright.  A  more  or  less  profound  anemia  of 
the  brain  and  of  the  skin  accompanies  inflammatory  diseases  of  the 
abdominal  viscera. 

An  anemic  part  becomes  pale,  sOx'"ter,  and  cooler  than  normal;  its 
nutrition  and  function  are  impaired.  Long-continued  partial  anemia  of 
a  part  or  organ  leads  to  fatty  and  other  degenerations,  with  atrophy; 
complete  anemia  leads  to  necrosis. 

Local  hyperemia  is  an  increase  in  the  quantity  of  blood  in  a 
circumscribed  region  of  the  body.  It  may  be  active,  when  the  blood  is 
arterial,  or  passive,  when  there  is  an  accumulation  of  venous  blood. 

I.  Active  hyperemia,  or  congestion,  may  be  due  to  an  increased 
■demand  for  nutrition  in  the  part,  such  as  occurs  in  reparative  processes. 
Pathologically  it  may  be  due  to  a  dilatation  of  the  vessels  through 
vasomotor  influences,  central  or  peripheral  in  character.  This  occurs 
when  the  vasoconstrictor  influence  of  the  sympathetic  nerves  is  inter- 


12  PRACTICE  OF  MEDICINE 

rupted,  as  by  the  pressure  of  a  tumor,  or  when  the  vasodilators  in  the 
spinal  cord  are  stimulated,  as  sometimes  occurs  in  neuritis.  An  inter- 
esting example  of  it  is  seen  also  in  the  unilateral  flushing  of  the  face 
in  pneumonia.  Active  hyperemia  occurs  also  when  a  tissue  is  injured 
mechanically  or  chemically;  it  may  occur  as  a  reaction  from  local 
anemia.  A  collateral  hyperemia  sometimes  develops  in  consequence  of 
profound  anemia  in  another  part.  Hyperemia  is  always  present  in 
inflammation.  Increased  heat,  redness,  and  slight  swelling  of  the  part 
are  its  usual  manifestations.  Its  results  are,  at  first,  an  increase  of 
functional  activity;  later,  inflammation  or  degenerative  changes. 

2.  Passive  Hypereniia. — When  the  presence  of  an  increased  amount 
of  blood  is  due  to  a  retardation  or  arrest  of  the  flow  of  venous  blood 
from  the  region,  the  hyperemia  is  passive.  This  occurs  when  a  vein 
is  compressed  or  closed  in  any  manner.  It  varies  in  degree  from  a 
slight  retardation  to  a  complete  stoppage  (venous  stasis).  It  is  caused 
by  inflammation  of  the  vein  or  of  the  parts  around  it,  by  thickening  of 
its  walls  through  sclerosis,  calcification,  or  syphilitic  induration,  or  by 
compression  of  a  new  growth.  A  more  general  passive  hyperemia  is 
seen  in  the  various  organs,  especially  in  the  lungs  and  liver,  as  a  result 
of  valvular  disease  of  the  heart.  The  aff"ected  tissues  at  first  become 
swollen  and  intensely  red,  then  a  transudation  of  serum  occurs,  and 
edema  is  produced ;  later,  if  the  condition  continues,  fatty  degeneration 
and  ultimately  necrosis  may  take  place.  The  destroyed  area  is  sometimes 
replaced  by  new  fibrous  tissue  which  is  often  deeply  pigmented.  The 
condition  is  then  known  as  brown  ah'ophy.  The  best  example  of  it  is 
found  in  the  myocardium  as  a  result  of  arteriosclerosis  of  the  coronary 
arteries. 

Dropsy  and  Edema. — Dropsy  is  a  generic  term  and  embraces  all 
abnormal  accumulations  of  fluid  within  the  connective-tissue  spaces  and 
serous  cavities  of  the  body.  Although  the  condition  is  practically  the 
same  in  all  cases,  usage  has  given  us  several  names  for  the  designation 
of  dropsical  accumulations  in  different  regions.  When  only  the  connec- 
tive-tissue spaces  of  organs  are  involved,  it  is  spoken  qf  as  an  edema; 
an  accumulation  in  the  subcutaneous-tissue  spaces,  especially  those  of 
the  lower  extremities,  is  an  anasarca;  that  in  the  peritoneal  cavity, 
ascites;  in  the  pleural  cavity,  a  hyd?-othorax,  or  pleuritic  effusion.  WTien  in 
the  arachnoid  space  and  ventricles  of  the  brain,  it  is  a  hydrocephalus, 
and  when  in  the  pericardium,  a  hydropericardiu?n.  In  general  dropsy 
there  is  a  progressive  involvement  of  the  connective  tissue  spaces  and 
cavities. 

The  serous  and  connective  tissue  spaces  normally  contain  a  small 
quantity  of  plasma,  which  is  fairly  constant  in  each  part.  It  is  derived 
for  the  most  part  from  the  capillary  blood-vessels,  but  in  part,  perhaps, 
from  the  lymph-vessels.  Under  normal  conditions  the  plasma  is  taken 
back  into  the  circulation  after  it  has  remained  in  the  tissues  for  a  time, 
performing  its  function  of  supplying  nutrition.  Some  authors  refer  this 
return  of  the  fluid  entirely  to  the  action  of  the  lymph-vessels,  while  others 
believe  that  the  blood-vessels  are  even  more  active  in  picking  it  up.  A 
normal  condition  of  the  blood-vessel  walls  with  reference  to  permeability 
and  normal  blood  pressure  in  the  capillaries  is  regarded  as  essential 
to  the   maintenance  of  a  normal  quantity   of  this   fluid  in  the  spaces, 


PATHOLOGY  13 

and  it  has  been  suggested  that  osmosis  through  the  capillary  walls  is 
responsible  for  its  ebb  and  flow.  It  is  no  longer  regarded  as  a  product 
of  secretion. 

Causes  of  Dropsy. — i.  A  dropsical  accumulation  of  fluid  is  generally 
the  result  of  a  disturbance  of  the  relation  between  transudation  and 
absorption.  This  in  turn  may  be  due  to  ((2)  increased  blood  pres- 
sure, (/')  changes  in  the  capillary  walls  which  render  them  more  perme- 
able to  the  plasma,  (r)  changes  in  the  composition  of  the  blood  which 
render  it  more  diffusible,  or  ((^/)  influences  which  otherwise  retard  the 
return  of  plasma  to  the  circulation.  The  first  of  these  causes,  an 
increased  blood  pressure,  is  generally  due  to  a  "retardation  of  the  capil- 
lary and  venous  circulation  and  is  therefore  on  the  order  of  a  hyperemia. 
It  is  a  passive  hyperemia,  an  increase  of  venous  rather  than  of  arterial 
pressure.  Weakness  of  the  circulation  favors  the  transudation  of  serum, 
and  the  best  examples  of  dropsical  effusion  are  seen  in  cases  of  heart 
disease  after  compensation  has  failed  and  the  blood  has  become  stag- 
nated in  the  veins. 

2.  Arterial  Edevia. — The  existence  of  a  strictly  arterial  edema  has 
been  questioned.  The  term  is  generally  limited  to  the  edematous  con- 
dition in  an  inflamed  area,  always  a  transient  condition.  The  permea- 
bility of  the  vessel  walls  is  increased  by  thermal  or  chemical  injury  as 
well  as  by  degenerative  changes  consequent  upon  disease. 

3.  Alterations  in  the  character  of  the  blood  are  looked  upon  as  a 
most  important  factor  in  the  production  of  dropsies  of  renal  origin. 
A  hydremia  has  been  described  in  these  cases  in  which  the  blood  becomes 
watery  through  a  reduction  of  its  solid  constituents,  but  the  condition 
cannot  always .  be  demonstrated  even  in  advanced  stages  of  nephritis. 
The  hydremia  has  been  referred  also  to  the  retention  of  toxic  substances 
in  the  blood  owing  to  an  inability  of  the  kidneys  to  remove  them.  A 
third  explanation  refers  it  to  deficient  oxidation. 

4.  Interference  with  the  flow  of  lymph  through  the  larger  channels 
may  sometimes  be  a  cause  of  dropsical  accumulations,  especially  in  the 
thoracic  and  peritoneal  cavities.  Probably  nothing  short  of  an  ob- 
struction of  the  thoracic  duct  is  capable  of  acting  in  this  way,  and 
such  obstruction  is  known  to  increase  an  already  existing  ascites. 

5.  The  nervous  system  is  not  regarded  as  operative  in  the  produc- 
tion of  dropsical  accumulations,  except  so  far  as  the  vasomotor  nerves 
may  sometimes  b&  involved  in  it. 

6.  In  some  instances  an  accumulation  of  fluid  replaces  tissue  that 
has  been  lost,  as  when  a  portion  of  the  brain  or  spinal  cord  has  been 
removed.    This  is  called  edema  ex  vacuo. 

The  fluid  of  a  pure  edema  corresponds  in  its  saline  and  aqueous  com- 
position to  the  serum  of  the  blood,  but  it  is  deficient  in  albumin.  The 
fluid  of  ascites  is  richer  in  albumin  than  is  that  of  edema.  When  the 
effusion  is  due  to  disease  of  the  blood-vessel  walls,  it  contains  more 
albumin  and  as  a  rule  a  larger  number  of  blood-cells. 

The  swelhng  which  accompanies  an  edema  varies  from  a  slight  tumefac- 
tion to  the  most  extreme  distention.  In  extreme  anasarca  the  skin  becomes 
tense  and  glazed,  and  it  is  often  rent  to  permit  the  escape  of  the  fluid. 
The  swollen  part  usually  appears  anemic;  it  may  be  cyanotic;  it  feels 
doughy  or  sodden,   pits  on  pressure,   and    degeneration  or  necrosis  is 


14  PRACTICE  OF  MEDICINE 

apt  to  result.  Edematous  organs  are  lighter  in  color  and  ''juicy"'  when 
incised.  Their  function  is  impaired.  The  gravity  of  the  condition  de- 
pends largely  upon  the  part  affected.  Edema  of  the  brain,  glottis,  or 
lungs  is  always  attended  with  danger  to  life,  and  a  general  dropsy 
with  serious  failure  of  the  circulation. 

Hemorrhage. — Hemorrhage  signifies  the  escape  of  blood  from  a  vessel — 
the  escape  of  all  the  elements  of  the  blood  in  contradistinction  to  the 
escape  of  only  the  plasma,  as  in  edema.  It  may  be  external  or  internal. 
In  the  latter  form,  the  blood  is  retained  within  the  tissues  or  one  of  the 
inclosed  cavities  of  the  body.  In  its  origin,  the  hemorrhage  may  be 
arterial,  venous,  or  capillary.  Arterial  hemorrhage  occurs  only  through 
a  lesion  of  the  vessel-wall  (rhexis) ;  venous  and  capillary  bleeding  may 
take  place  either  through  a  lesion  of  the  vessel-wall,  or  more  gradually 
by  diapedesis,  a  stepping  out  of  the  elements  of  the  blood  through  the 
normal  spaces  in  the  vessel-walls.  A  migration  of  the  leucocytes  from 
the  vessels  into  the  adjacent  tissues  is  normal ;  but  when  the  red  corpus- 
cles thus  escape,  it  constitutes  a  diapedesis  and  is  pathological.  The 
principal  causes  of  diapedesis  are  degenerative  changes  in  the  vessels 
due  to  the  action  of  toxic  substances,  mechanical  or  thermal  injury, 
or  arrest  of  the  circulation.  Hemorrhage  of  this  character  is  not  usually 
great  in  quantity.  * 

Causes. — The  causes  of  arterial  hemorrhage  are :  (rt')  Laceration  or 
rupture  of  the  wall  of  the  vessel  while  in  a  state  of  health,  a  surgi- 
cal condition,  ((^)  disease  of  the  blood-vessel,  (r)  increased  blood  pres- 
sure, and  (^)  nervous  influence.  Disease  may  affect  the  blood-vessel  either 
internally  or  externally.  The  most  important  internal  affections  are  fatty 
and  other  degenerations  and  sclerosis,  often  leading  to  miliary  or  larger 
aneurisms.  Degeneration  of  the  tunics  of  the  vessel  results  chiefly  from 
the  toxemia  of  the  infections  or  from  malnutrition  incident  to  fever, 
anemia,  or  the  cachectic  states.  Among  the  causes  of  external  disease 
of  the  vessels  are  the  pressure  of  tumors,  suppuration,  and  tuberculosis, 
thermal  and  chemical  irritation. 

Increased  blood  pressure  is  sometimes  spoken  of  as  absolute  when 
it  follows  violent  muscular  effort,  paroxysms  of  intense  joy  or  grief, 
the  coughing  of  acute  bronchitis  or  pertussis,  and  convulsions.  It  is 
relative  when  due  to  the  withdrawal  of  normal  external  pressure,  as  in 
asphyxia,  or  when  induced  by  ascent  to  high  altitudes. 

Hemorrhage  of  nervous  origin  is  due  to  paralysis  of  the  vasomotor 
nerves  or  to  a  reflex  mechanism  which  is  not  fully  understood.  Bleeding 
from  the  nose,  lungs,  stomach,  or  bladder,  or  into  the  substance  of  such 
organs  as  the  kidneys  and  suprarenal  bodies  is  sometimes  of  this  char- 
acter. Another  interesting  class  of  hemorrhages  is  exemplified  in  the 
stigmatization  of  hysterical  ecstasy,  in  which  blood  infiltrates  the  skin 
of  different  regions,  most  frequently  those  wounded  in  the  crucifixion. 

Some  persons  have  a  natural  tendency  to  hemorrhage;  they  are 
called  bleeders,  and  the  condition  is  known  as  the  hemorrhagic  diathesis. 
When  inherited,  it  constitutes  hemophilia.  The  hemorrhagic  diathesis 
is  sometimes  acquired  by  persons  not  previously  predisposed  to  hemor- 
rhage, in  the  course  of  typhus,  yellow  fever,  cholera,  the  plague,  scurvy, 
hypertrophic  cirrhosis  of  the  liver,  septicemia,  pernicious  anemia,  purpura 
hemorrhagica,  and  certain  other  aftcctions. 


PATHOLOGY  15 

Varieties. — External  hemorrhages  are  generally  classified  according 
to  their  source.  Hemorrhage  of  the  nose  is  designated  epistaxis,  hemor- 
rhage of  the  lungs  hemoptysis,  that  of  the  stomach  hematemesis,  that 
of  the  intestine  enterrhagia.  Uterine  hemorrhage  is  subdivided  into 
menorrhagia  and  metrorrhagia,  occurring  during  or  between  the  men- 
strual periods. 

Interiial  hemorrhages  receive  their  nomenclature  in  part  from  their 
location  and  in  part  from  their  character.  Hemorrhage  into  the  peri- 
cardium is  called  hemopericwrdiuni,  that  into  the  pleural  cavity  hemo- 
thorax. A  hemorrhage  into  or  beneath  the  skin  or  a  mucous  mem- 
brane is  an  ecchyjtiosis;  if  this  is  confined  to  small  areas  and  it.  produces 
small  reddish  or  dark  brown  spots  these  are  called  petechice.  A  larger 
accumulation  of  blood  in  a  tissue  is  a  suffusion,  but  if  the  accumula- 
tion be  large  enough  to  form  a  tumor  it  is  call  a  hematoma.  (See  also 
Infarction.) 

Results. — Sudden  profuse  hemorrhage  of  any  kind  produces  pro- 
found prostration,  syncope,  or  shock.  The  individual  is  rendered  uncon- 
scious and  death  may  result.  If  not  fatal,  the  unconsciousness  is 
recovered  from  as  soon  as  the  blood-vessels,  by  contraction  and  by 
appropriation  of  fluid  from  the  tissues,  have  in  a  measure  compensated 
for  the  loss.  Hemorrhages  are  spontaneously  arrested  by  the  decrease 
of  blood  pressure,  by  the  retraction  of  the  injured  vessel,  by  the  pressure 
of  overlying  structures,  or  by  coagulation  of  the  blood  at  the  point  of 
hemorrhage.  A  more  or  less  profound  secondary  anemia  may  result 
from  repeated  small  losses  of  blood. 

A  hemorrhagic  accumulation  of  blood  is  reduced  in  size  by  absorption 
of  the  serum  after  coagulation  has  taken  place.  The  remaining  coagu- 
lum  may  also  be  more  or  less  completely  taken  up  by  absorption, 
especially  when  it  is  in  a  serous  cavity.  It  is  sometimes  replaced  by  the 
formation  of  new,  deeply  pigmented  fibrous  tissue.  The  coagulum,  on  the 
other  hand,  may  undergo  decomposition,  through  the  action  of  micro- 
organisms, and  serious  toxemia  may  follow.  In  other  instances  the 
clot  becomes  encapsulated  and  remains  indefinitely  as  a  harmless  cyst. 

Thrombosis. — Coagulation  of  blood  within  the  heart  or  blood-vessels 
during  life  is  termed  thrombosis.  It  may  occur  anywhere  within  the 
chambers  of  the  heart,  in  the  arteries,  capillaries,  or  veins.  The  coagu- 
lum is  called  a  thrombus. 

Causes. — The  recognized  causes  of  thrombosis  are  damage  or  removal 
of  the  endothelium  lining  the  vessel,  slowing  of  the  blood-current,  and 
changes  in  the  blood  which  favor  its  coagulation,  i.  Injury  of  the 
vessel-wall  is  the  most  important.  It  is  doubtful,  indeed,  whether  throm- 
bosis ever  occurs  independently  of  such  defect.  The  most  common  causes 
of  such  damage,  aside  from  trauma,  are  fatty  or  other  degeneration  of 
the  intima,  inflammation  of  the  vessel  or  of  surrounding  tissues,  arterio- 
sclerosis, and  such  dilatation  as  occurs  in  aneurism,  enlargement  of  the 
heart  cavities,  and  varicosity.  Inflammation  is  a  more  frequent  cause 
in  the  veins  than  in  the  arteries.  The  intima  of  the  vessel  may  be  im- 
paired also  by  deficiency  of  nutrition,  producing  fatty  degeneration ; 
by  foreign  bodies,  parasites,  or  neoplasms.  The  endocardium  may  be 
injured  by  inflammation,  and  both  these  membranes  by  the  toxic  agents 
developed  in  infectious  diseases. 


1 6  PRACTICE  OF  MEDICINE 

2.  Slowing  of  the  blood-stream  probably  does  not  produce  throm- 
bosis so  long  as  the  walls  of  the  vessel  are  intact.  It  is  believed  that 
coagulation  is  often  prevented  in  cases  of  advanced  atheromatous  dis- 
ease, for  example,  by  the  rapidity  of  the  current.  A  slowing  of  the 
current  aids  coagulation  by  favoring  the  preliminary  accumulation  of 
the  blood-cells  along  the  sides  of  the  vessel  and  their  attachment  at 
any  defective  point.  This  tendency  to  stagnation  of  the  blood  may 
result  from  weakness  of  the  heart,  diminished  elasticity,  with  either 
dilatation  or  contraction  of  the  vessel.  The  circulation  is  normally  slow 
in  the  cerebral  veins  and  sinuses,  and  in  the  veins  of  the  pelvis  and  lower 
extremities,  especially  when  varicose  dilatation  is  present.  These  are 
therefore  frequent  seats  of  coagulation.  When  the  heart  is  dilated  the 
apices  of  the  ventricles,  the  space  between  the  trabeculae  and  the 
auricular  appendages  are  frequent  sites  of  thrombosis.  In  the  veins 
the  thrombus  generally  forms  just  back  of  the  valves. 

The  thrombus  is  composed  of  superimposed  layers.  The  first  layer 
is  known  as  the  primai-y  th?'o?7ibus,  subsequent  layers  as  secojidary.  A 
thrombus  remaining  attached  to  the  side  of  the  vessel  is  a  lateral  throm- 
bus; when  it  completely  obstructs  the  vessel,  it  is  an  obliteratmg  throm- 
bus. Peculiar  ball  thrombi  have  been  described  as  occurring  in  the  heart. 
They  are  polyp-like  masses  attached  by  only  a  slender  pedicle  or  lying 
free  within  the  auricle. 

A  thrombus  which  has  formed  in  blood  that  has  almost  stagnated 
in  the  vessel  is  dark  and  soft  and  resembles  a  post-mortem  clot.  When 
it  forms  in  circulating  blood  it  is  yellow  or  white  in  color.  These 
facts  depend  upon  the  changed  circulation  that  results  from  retardation. 
In  the  normal  circulation  the  red  corpuscles  and  blood-plates  travel 
through  the  center  of  the  current,  leaving  a  zone  along  the  vessel-wall 
consisting  of  plasma  and  leucocytes.  When  the  circulation  becomes 
slow,  the  blood-plates  leave  the  central  zone  and  cling  in  little  clumps  to 
the  vessel-wall.  Leucocytes  soon  join  the  accumulation  and  fibrin  is 
then  formed.  The  white  thrombus  is,  therefore,  composed  of  blood-plates, 
leucocytes,  and  fibrin.  The  importance  of  the  blood-plates  in  coagulation 
of  extravasated  blood,  as  well  as  that  within  the  vessels,  has  been 
studied  by  Arnold  and  others,  who  regard  them  as  the  most  important 
factor. 

Results. — Collateral  circulation  may  be  established  so  quickly  after 
the  formation  of  a  throm^bus  as  to  prevent  serious  consequences;  but 
in  organs  provided  with  terminal  arteries,  and  when  the  anastomotic 
circulation  is  poor,  infarction  results.  Thrombi  are  sometimes  removed. 
The  exact  process  by  which  this  is  accomplished  is  not  known,  but  the 
softening  which  is  known  to  occur  in  them  is  doubtless  one  step  in  it. 
They  may  be  organized.  In  other  words,  the  thrombus  may  be  replaced 
by  new  vascular  connective  tissue  which  is  nourished  from  the  vessel- 
wall  as  though  it  were  a  normal  part  of  the  body. 

The  other  results  of  thrombosis  are  ((/)  changes  in  the  vessel-wall, 
(^)  obstruction  of  the  circulation,  and  (^)  embolism. 

a.  When  the  thrombus  becomes  organized,  the  vessel-wall  is  at  first 
thickened,  but  it  later  undergoes  atrophy.  It  may  undergo  suppurative 
softening  through  the  action  of  micrococci ;  suppurative  arteritis  or  phle- 
bitis is  then  produced  and  septic  infection  of  the  system  may  follow. 


PATHOLOGY  17 

b.  Obstruction  of  the  circulation  produces  results  which  vary  with  the 
size  of  the  vessel,  its  location,  the  character  of  its  anastomotic  connections, 
and  the  suddenness  of  the  obstruction.  It  is  usually  of  less  gravity 
than  embolism.  WTien  an  artery  is  obstructed,  the  result  is  a  local  anemia, 
•which,  if  continued,  leads  to  degenerative  changes  in  the  parts  supplied. 
When  a  vein  is  closed,  con- 
gestion   and  edema    follow.  d 

A  not  unusual  example    of      ^^^?®^^^^^P  v.'-^^<r(s 
venous    thrombosis    is  seen         ^Q^^^S^Q\'^P^£>>'i$^rM^{ 
in  the    plugging  of  the  ihac        -^^^^g-D^OC^fi^^^'^^^'®' 
or    femoral    vein    after    ty-       r-^'^OSDQ^'.^^'' 
phoid    fever  or    in  the  late       bjM^^^^J^ 
stages  of  tuberculosis    and 
other    chronic  diseases.       In  Fig.  i. -Greatly  retarded  blood-stream,    a.   Ax- 

the    latter    conditions    it    is       ial  stream      b,    Pei-jpheral    ^one  ^^•ith    blood-plates 
.6%  -A.  collection  ot  blood-plates.     (Alter  hberth   and 

known  as  marasmic  throm-      Schimmelbusch.) 
bosis. 

Embolism. — Embolism  is  the  lodgment  of  any  solid  substance,  carried 
by  the  blood,  in  a  vessel  whose  lumen  is  too  small  to  permit  its  further 
passage.  The  solid  substance  while  passing  through  the  vessel  is  called 
an  embolus.  The  most  frequent  forms  of  embolus  are :  (<?)  A  fragment  of 
clotted  blood  that  becomes  detached  from  a  thrombus ;  Qt)  vegetations 
from  the  heart  cavities  in  endocarditis;  {/)  fragments  of  calcareous 
matter  separated  from  atheromatous  plates;  (^)  pieces  of  neoplasms, 
especially  sarcoma,  which  have  penetrated  the  vessel;  (<?)  pigment  masses, 
as  in  malaria;  (/)  air;  {g)  fluid  fat;  (/z)  hyalin  masses  produced  by 
burns;  (z)  clumps  of  bacteria;  and  (7)  the  scolices  of  echinococcus  or 
other  parasites.  A  retrograde  embolism  is  described  in  which  the  embo- 
lus travels  in  a  direction  opposite  to  the  usual  course  of  the  blood, 
especially  in  the  hepatic  veins.  It  is  said  to  sometimes  occur  in  con- 
ditions producing  increasing  intrathoracic  pressure,  as  in  the  paroxysms 
of  whooping-cough.  The  location  of  the  embolism  depends  for  the  most 
part  upon  the  source  of  the  embolus.  An  embolus  from  the  veins  and 
right  side  of  the  heart  lodges  in  the  lungs ;  rarely,  it  is  broken  up  in 
the  lung  into  small  fragments,  which  pass  on  into  the  general  circulation; 
this  is  true  especially  of  fat-emboli.  An  embolus  from  the  left  heart 
and  arteries  passes  into  the  general  circulation  and  most  frequently 
finds  lodgment  in  the  brain,  kidneys,  or  spleen.  It  may  lodge  in  other 
peripheral  vessels  where  it  is  less  productive  of  injury. 

Results. — The  immediate  results  depend  upon  the  character  of  the 
embolus  and  the  size  and  location  of  the  vessel  obstructed,  (i)  Instant 
death  may  result  from  the  occlusion  of  a  large  vessel  in  the  brain,  a 
main  branch  of  the  pulmonary  artery,  or  one  of  the  coronary  arter- 
ies of  the  heart.  Less  rapidly  fatal  results  may  follow  the  develop- 
ment of  a  thrombus  beyond  an  incomplete  embolism.  (2)  An  embolism 
may  undergo  softening  and  be  removed;  it  may  become  organized,  or 
the  development  of  collateral  circulation  may  prevent  the  more  serious 
consequences. 

(3)  Profound  anemia  is  always  produced  in  the  area  dependent  upon 
the  obstructed  vessel  for  its  blood  supply,  and,  when  collateral  circulation 
is  not  promptly  established,  this  may  be  followed  by  an  infarction. 


i8 


PRACTICE  OF  MEDICINE 


Infarction. — By  infarction  is  meant  the  occlusion,  by  an  embolus  or 
thrombus,  of  a  small  artery  having  poor  anastomotic  connections,  and 
the  changes  thus  produced.  It  is  limited,  therefore,  chiefly  to  parts 
supplied  with  terminal  or  end  arteries,  as  the  heart,  kidney,  spleen, 
base  of  the  brain,  and  the  retina.  Infarcts  are  usually  classified  as 
hemorrhagic  or  red,  and  anemic  or  white.  If  the  anastomotic  circulation 
of  the  affected  region  is  sufficiently  abundant  to  permit  a  return  flow 
of  blood  into  the  area  after  arrest  of  the  circulation,  the  infarct  ap- 
pears hemorrhagic  or  red;  otherwise  the  area  remains  anemic,  has  at 
most  a  yellowish  or  gray  color,  and  is  called  a  white  infarction.  The 
external  zone  of  an  infarct  is  always  red,  however,  on  account  of  hem- 
orrhage and  congestion  of  the  surrounding  tissues.  Wliite  infarction 
occurs  almost  exclusively  in  the  terminal  arteries. 


Fig.  2. — Edge  of  recent  hemorrhagic  infarct  of  lung,  a,  Interalveolar  septa  with 
engorged  capillaries,  b,  Septa  showing  nuclei,  c,  Vein  with  red  thrombus,  d,  Alveoli 
filled  with  coagulum.     (Ziegler.) 

An  infarction  is  almost  always  situated  in  the  peripheral  zone  of  an 
organ.  In  form  it  resembles  a  cone  or  wedge,  with  the  base  outward. 
Irregular  shapes  are  encountered  when  several  small  vessels  in  the  same 
territory  are  simultaneously  obstructed. 

Changes  in  the  Infarct. — An  infarct  generally  undergoes  degenerative 
changes.  In  the  hemorrhagic  form  these  consist  in  a  breaking  down  of 
the  blood,  a  removal  of  the  fluid  portion,  and  the  growth  of  a  deeply 
pigmented  cicatrix  to  replace  the  destroyed  tissue.  In  the  white  infarct, 
coagulation  necrosis  takes  place,  and  this  may  be  followed  by  caseation 
or  absorption  and  the  formation  of  a  nonpigmented  cicatrix.  If  micro- 
organisms gain  entrance,  suppuration  may  be  set  up,  and  the  infarction 
sometimes  becomes  the  nidus  of  more  extensive  infection  and  the  develop- 
ment of  metastatic  abscesses  in  more  or  less  remote  parts. 

The  term  infarction  has  recentl)^  been  employed,  rather  unfortunately, 
to  designate  the  infiltration  of  the  renal  tubules  or  tissue  spaces  with 
blood,  pigment,  or  the  salts  of  the  urine  or  bile.     The  most  important 


FEVER  19 

of  these  are  the  uric  aeid,  calcareous,  hematoidin,  melanin,  and  bihrubin 
infarctions.  The  uric  add  infarct  is  found  in  the  kidnej'S  of  the  fetus 
or  newborn  infant  and  in  the  tubules  of  the  kidneys  in  adult  gouty- 
subjects.  Sodium  urate  infarcts  occur  in  the  same  class  of  adults. 
Calciujn  infarcts  occur  in  the  kidneys  of  aged  persons,  in  destructive 
diseases  of  bone,  and  after  poisoning  with  such  mineral  substances  as 
mercuric  chlorid,  phosphorus,  and  bismuth.  Hematoidin  infarcts  are 
associated  with  hemoglobinuria,  hemoglobinemia,  and  methemoglobin- 
emia following  infection,  poisoning,  or  extensive  burns.  The  melanin 
infarct  is  rare,  occurring  in  the  form  of  casts  of  the  renal  tubules  in 
metastasis  from  melanotic  sarcoma.  Bilirubin  infarction  is  seen  as  casts 
of  the  collecting  tubules  in  some  cases  of  obstructive  jaundice. 

FEVER. 

Elevation  of  the  temperature  of  the  body  amounting  to  more  than 
1°  C.  (1.8"  F.)  above  the  normal,  37°  C.  (98.6°  F.),  is  the  most  promi- 
nent feature  of  the  condition  known  as  fever.  In  a  majority  of  the 
febrile  diseases  the  temperature  ranges  between  2)'^°  C.  (100.4°  F.)  and 
40°  C.  (104°  F.).  The  condition  is  known  also  as  pyrexia.  \^Tien  the 
temperature  rises  above  40. 5*^  C.  Ci°5°  E.),  the  condition  is  termed 
hyperpyrexia.  But  elevation  of  the  temperature  is  only  one  of  many 
disturbances  characteristic  of  fever.  The  action  of  the  heart  is  accelerated, 
the  secretion  of  nearly  all  the  glands  is  impaired,  and  the  processes  of  me- 
tabolism are  deranged.  The  destructive  processes  (katabolism)  are  for  the 
most  part  increased,  while  nutrition  is  to  a  great  extent  suspended. 

The  principal  source  of  normal  animal  heat  is  the  combustion  of 
food  substances  involving  the  absorption  of  oxygen  and  the  liberation 
of  carbon  dioxid;  a  small  part*  of  the  heat  is  derived  from  the  secreting 
glands  and  probably  other  processes.  The  temperature  of  the  body  in 
health  remains  almost  constant,  owing  to  the  balance  which  is  maintained 
by  the  nervous  system  between  the  production  of  heat  and  its  dispersion. 
The  chief  avenues  of  heat  dissipation  are  :  radiation  from  the  surface  of 
the  body,  the  expired  air,  and  the  excreta.  It  is  generally  believed  that 
at  least  two  centers  are  engaged  in  the  control  of  temperature,  one 
governing  heat  production,  the  other  governing  its  dissipation. 

Febrile  elevation  of  temperature  suggests  overproduction  of  heat, 
underelimination,  or  both.  The  overproduction  of  heat  represents  an 
increased  combustion,  or  oxidation,  especially  of  the  albuminous  sub- 
stances of  the  body,  with  increased  discharge  of  carbon  dioxid  and 
nitrogenous  waste,  especially  urea,  creatin,  and  creatinin.  The  increase 
in  elimination  of  nitrogen  compounds  usually  amounts  to  from  70  to 
100  per  cent,  of  the  normal,  but  may  reach  300  per  cent. 

Causes  of  Fe/er. — i.  Since  the  temperature  is  regulated  by  the  ner- 
vous system,  the  simplest  form  of  its  derangement  is  observed  in  purely 
nervous  conditions.  In  childhood  and  during  convalescence  from  disease, 
owing  to  the  instability  of  the  nervous  system,  the  most  trifling  influ- 
ences are  capable  of  causing  elevation  of  temperature.  The  fever  of 
hysteria  is  probably  due  to  an  interruption  of  nervous  control,  but 
in  many  cases  it  is  difficult  to  exclude  from  its  production  such  influ- 
ences as  violent  muscular  action  or  the  withdrawal  of  peripheral  circu- 


20  PRACTICE  OF  MEDICINE 

lation.     Either  muscular  or  nervous  exertion  is  capable  of  increasing 
the  elevation  of  temperature  in  the  course  of  a  febrile  disease. 

2.  Exposure  to  high  temperature  causes  fever  in  such  conditions  as 
sunstroke  or  heat-prostration,  after  a  derangement  of  the  nervous  con- 
trol, or,  as  some  believe,  after  toxic  substances  have  been  developed  in 
the  system  as  a  result  of  the  exposure. 

3.  The  fever  of  the  infectious  diseases  is  believed  to  be  caused  by 
the  action  of  the  toxins  upon  the  nervous  system.  Albumoses,  peptons, 
various  unformed  ferments,  as  pepsin,  fibrin-ferment,  diastase,  and  many 
others,  are  capable  of  causing  elevation  of  temperature  when  introduced 
into  the  blood,  and  it  is  probable  that  we  have  an  example  of  their 
action  in  the  fever  of  the  autointoxications.  The  toxic  bodies  resulting 
from  mechanical  injuries  of  tissues  sometimes  produce  fever. 

The  temperature  range  of  the  febrile  diseases  is  generally  divided 
into  three  stages:  (i)  the  invasion;  (2)  the  fastigium,  or  stage  of 
greatest  intensity,  and  (3)  the  decline.  The  duration  of  the  diiferent 
stages  and  the  peculiarities  in  the  course  of  each  are  important  in  giving 
individuality  to  the  disease,  and  these  features  of  the  invasion  are 
particularly  valuable  in  diagnosis. 

The  invasion  is  generally  announced  in  the  acute  diseases  by  a  rigor 
or  by  chilly  sensations.  In  children  a  convulsion  or  vomiting  frequently 
takes  the  place  of  the  chill.  Benedetto  de  Luca  looks  upon  the  chill  as 
a  result  of  the  altered  biochemical  processes  for  the  production  of  heat. 
When  the  bacteria  or  toxins  have  incited  these  to  the  production  of  a 
temperature  of  40°  C,  for  example,  and  the  body  is  still  at  38°  C,  a 
chill  occurs,  just  as  it  would  if  the  temperature  of  the  body  were 
reduced  to  35^  C.  while  the  mechanism  was  acting  for  the  production  of 
38°  C.  During  the  invasion  of  an  infection  the  temperature  generall)^ 
shows  a  progressive  daily  rise;  sometimes  it  attains  its  height  within 
the  first  24  hours.  In  the  fastigium,  it  pursues  a  more  or  less  uniform 
daily  fluctuation.  The  decline  is  by  crisis  or  lysis.  In  crisis,  the  temper- 
ature drops  to  the  normal  within  from  24  to  36  hours;  in  lysis,  several 
days  are  occupied  by  the  decline. 

Results  of  Fever. — Fever  is  always  attended  with  changes  in 
the  blood,  disturbance  of  various  functions,  and  wasting,  but  it  is 
difficult  to  determine  to  what  extent  these  phenomena  are  a  result  of 
the  high  temperature  and  how  far  they  are  due  to  the  influences  which 
give  rise  to  the  elevation  of  temperature.  A  moderate  fever  of  long 
duration  is  more  serious  in  its  consequences  than  a  much  higher  temper- 
ature elevation  of  short  duration.  Hyperpyrexia  is  always  regarded 
as  dangerous.  The  chief  dangers  are  the  degenerations  of  the  heart, 
voluntary  muscles,  and  nervous  system. 

The  elevation  of  the  temperature  in  fever  is  not  looked  upon  as 
necessarily  and  invariably  evil  in  its  effects.  It  is  probably  in  many 
instances  an  effort  of  nature  to  destroy  the  infection,  since  the  vitality 
of  many  micro-organisms  is  impaired  by  increased  temperature. 

RETROGRADE  PROCESSES. 

Atrophy.— In  a  restricted  sense,  atrophy  signifies  a  diminution  of  the 
size  of  an  organ  or  tissue,  without  structural  or   chemical   change.     As 


RETROGRADE  PROCESSES  21 

a  rule,  however,  it  is  accompanied  with  degeneration;  in  other  words, 
the  atrophy  is  degenerative  in  character.  The  term  aplasia  is  applied 
to  local  absence  of  development  from  birth  or  from  an  early  period  of 
life,  and  to  the  lack  of  development  of  the  entire  body  which  is  seen  in 
dwarfs.  Hypoplasia  signifies  a  partial  development.  It  is  frequently 
seen  in  the  central  nervous  system,  as  in  microcephalus  and  in  undevel- 
oped genitourinary  organs. 

A  physiological  atrophy  occurs  in  the  thymus  gland,  the  Wolffian 
bodies,  and  in  the  fetal  blood-vessels. 

Causes  of  Atrophy. — The  most  frequent  causes  of  atrophy  are  mal- 
nutrition, loss  of  function,  perversion  of  trophic  nervous  influence,  and 
excessive  waste. 

Malnutrition  may  be  general  or  local.  Defective  metabolism,  a  failure 
to  assimilate  nutriment,  is  probably  the  most  frequent  form  of  malnu- 
trition. We  see  the  results  of  a  general  lack  of  nutrition  in  the  atrophy 
of  old  age,  when  the  tissues  begin  to  lose  their  vigor.  It  is  sometimes 
associated  with  anemia,  marasmus,  and  cachectic  conditions. 

Local  atrophy  is  generally  the  result  of  partial  arrest  of  the  circula- 
tion of  a  part,  as  through  compression  by  cicatricial  tissue,  neoplasms,  or 
aneurisms.  It  is  also  exemplified  in  the  corset  liver  and  in  the  wasting 
of  bone  in  deformities. 

Loss  of  function  produces  general  atrophy,  in  conditions  which  prevent 
the  individual  from  taking  sufficient  exercise;  or  local  atrophy,  when 
it  is  confined  to  only  a  part.  The  atrophy  of  a  gland  whose  function 
has  ceased,  that  of  a  muscle  that  is  paralyzed,  or  of  a  nerve  that  is 
isolated  from  its  center,  are  examples  of  local  atrophy.  We  do  not  know, 
however,  to  what  extent  these  atrophies  are  the  result  of  a  loss  of  trophic 
nervous  influence  and  how  far  the  result  merely  of  interruption  of  function. 
Neuropathic  atrophy  is  seen  also  in  such  central  disturbances  as  pro- 
gressive bulbar  paralysis,  in  paresis,  and  in  diseases  of  the  anterior 
horns  and  gray  matter  of  the  cord,  as  polyomyelitis  anterior,  and  pro- 
gressive hemiatrophies. 

The  most  frequent  examples  of  atrophy  from  excessive  waste  are 
seen  after  profuse  or  repeated  hemorrhages,  suppuration,  and  excessive 
discharges  of  albumin  or  sugar.  The  progress  of  the  atrophy  is  often 
slow  in  the  latter  diseases. 

All  tissues  are  not  equally  subject  to  atrophic  change.  In  general 
atrophy,  the  adipose  tissue  of  the  body  is  first  consumed;  next  the 
muscles;  the  heart  and  central  nervous  system  are  usually  the  last 
to  be  reduced. 

Cloudy  swelling  is  a  minutely  granular  parenchymatous  degeneration 
of  the  cell,  through  which  it  is  enlarged  and  rendered  opaque.  Its  most 
frequent  seats  are  the  parenchyma  cells  of  the  liver,  kidneys,  and  other 
organs,  and  the  muscle  fibers.  The  mode  of  its  production  is  not  under- 
stood; by  some  investigators  it  is  regarded  as  a  precipitation  of  the 
protoplasm  of  the  cell.  In  some  instances,  particularly  in  febrile  diseases, 
it  is  probably  due  to  disturbance  of  metabolic  processes.  It  is  always 
present  in  a  tissue  that  is  inflamed. 

Causes. — Cloudy  swelling  is  often  attributed  to  either  general  or  local 
malnutrition,  but  a  more  frequent  cause,  no  doubt,  is  intoxication, 
cither  by  the  products  of  infectious  organisms  or  through  the  presence 


2  2  PRACTICE  OF  MEDICINE 

of  other  organic  or  inorganic   substances.     Increased  cellular    activity 
incited  by  abnormal  nervous  stimulus  may  produce  it. 

The  effects  upon  the  cell  are  enlargement  and  loss  of  contour;  and 
the  normal  features  of  the  cell  are  replaced  by  exceedingly  fine  granules 
which  give  it  a  cloudy  appearance.  Later,  vacuolization  may  occur. 
The  function  of  the  affected  part  is  impaired,  but  complete  recovery  is 
possible.  If,  however,  the  cause  of  the  degeneration  rem^ains  operative, 
the  process  is  readily  converted  into  fatty  degeneration. 

Fatty  degeneration  is  believed  to  consist  in  a  conversion  of  the 
protoplasm  of  the  cell  into  fat.  The  fatty  degeneration  which  occurs 
in  the  mammary  and  sebaceous  glands  in  the  elaboration  of  their  secretions 
is  physiological.  \^Tiether  or  not  this  is.  identical  with  what  occurs  in 
pathological  degeneration  is  not  known,  for  we  know  little  of  either 
process.  It  is  even  doubtful  whether  the  fat  may  not  be  derived  from 
a  metamorphosis  of  such  substances  as  sugar,  glycogen,  or  mucin^  which 
are  also  constituents  of  many  cells,  as  well  as  from  proteid  matter.  The 
fat  appears  at  first  in  the  form  of  minute  granules ;  later,  by  the  union 
of  granules,  larger  or  smaller  droplets  are  formed.  The  droplets  are 
not  so  large  as  those  generally  seen  in  fatty  infiltration,  a  fact  which  is 
regarded  as  of  importance  in  the  difterentiation  of  the  two  conditions, 
though  it  is  not  always  sufficiently  marked  to  distinguish  them. 

Causes. — Fatty  degeneration  may  be  a  primary  change,  but  it  is 
more  frequently  secondary.  It  often  follows  cloudy  swelling,  less  fre- 
quently coagulation  necrosis,  amyloid  or  other  degenerations.  In  many 
cases  it  results  from  intoxication  with  the  toxins  of  disease;  less  fre- 
quently that  of  such  metallic  poisons  as  phosphorus,  arsenic,  and  lead. 
It  may  result  also  from  the  action  of  carbon  dioxid,  the  chlorates, 
some  of  the  coal-tar  products,  chloroform,  ether,  and  iodoform.  The 
other  important  causes  are  either  general  or  local  disturbances  of 
nutrition,  disturbed  metabolism,  alterations  in  then  utritive  supply,  or 
partial  arrest  of  circulation.  It  may  be  exceedingly  rapid  in  its  course, 
sometimes  developing  within  a  few  hours  in  phosphorus-poisoning,  or 
it  may  progress  very  slowly. 

Fatty  degeneration  occurs  under  the  most  varied  conditions.  It  is 
always  present  in  leukemia,  frequently  in  chlorosis,  pernicious  anemia, 
and  tuberculosis;  in  the  vicinity  of  inflammation,  in  tumors,  exuda- 
tions, thromboses,  embolisms,  and  it  may  appear  in  many  other  relations. 
The  parts  most  frequently  affected  are  the  parenchyma  of  the  liver, 
renal  tubules,  heart,  blood-vessels,  diaphragm,  and  various  other  tissues. 
The  affected  cells  become  large  and  may  rupture.  \Mien  this  occurs, 
the  fat  becomes  disseminated  and  may  be  absorbed,  liquefaction  may 
occur,  or  caseation,  often  with  the  production  of-  crystals  of  the  fatty 

^^  -,.  acids  and  cholesterin. 

f(f>-m      ^^^^       otjj  Results. — Fatty  degeneration    is  of  more 

^  \P^^ff        ^^^    *^v^r        serious  consequence  than   fatty  infiltration, 
^^^  °'W        for  it  implies  the  death  of  the  affected  cell. 

C|k.      ^^k        a^Qf.:       A  moderate  degree  of  degeneration  does  not 
W  ^^^m    ^tf!^'.°^Q      necessarily  cause  an  arrest  of  function  and 
^       ^^       ^';p/©}%*       possibly  may  be  recovered  from;   but  a  cell 
Fig.    3. -Fatty    liver-cells,      which   is  in   an   advanced  state  of  fatty  de- 
(Ziegier.)  generation  can  never  be  restored. 


ALBUMINOID  DEGENERATION  23 

Fatty  infiltration  consists  of  a  deposit  of  fat  within  the  cells.  It 
differs  from  fatty  degeneration  in  that  the  fat  is  formed  outside  of  the 
cell  and  merely  replaces  the  protoplasm  of  the  cell.  It  cannot  always 
be  distinguished  from  fatty  degeneration.  It  is  a  physiological  proc- 
ess in  the  growth  and  development  of  adipose  tissue,  as  well  as  in  the 
intestinal  epithelium  and  liver  parenchyma,  after  the  ingestion  of  fatty 
food. 

As  a  pathological  process  it  is  more  apt  to  occur  in  regions  nor- 
mally containing  fat,  as  in  the  subcutaneous  and  subserous  tissues,  in 
the  bone  marrow,  the'  liver,  the  mesentery  and  omentum,  under  the 
pericardium,  'about  the  kidneys,  and  between  the  muscles.  Fat  may  be 
deposited  in  a  tissue  as  a  substitute  for  a  part  that  has  been  destroyed 
or  that  has  undergone  atrophy. 

Causes. — Many  persons  inherit  a  predisposition  to  the  accumulation 
of  fat,  and  these  are  probably  more  liable  than  others  to  the  patholog- 
ical infiltration.  The  common  exciting  causes  of  it  are  the  excessive 
formation  of  fat  or  a  diminished  oxidation.  Both  these  influences  are 
doubtless  operative  in  many  wasting  diseases,  tuberculosis,  chlorosis, 
diabetes,  and  cachectic  conditions.  Lack  of  exercise  is  probably  an  im- 
portant  factor  in  its  production  in  tuberculosis  and  other  chronic 
cachexias. 

Results. — The  effect  of  fatty  infiltration  is  an  increase  of  the  size, 
diminution  of  color,  and  more  or  less  complete  loss  of  function  of  the 
cell.  But  the  fat  may  be  removed  and  the  cell  may  be  fully  restored 
to  its  normal  state  and  function.  On  the  other  hand,  continued  fatty 
infiltration  may,  chiefly  by  compression,  incite  a  fatty  degeneration  of 
the  protoplasm  of  the  cell. 

ALBUMINOID  DEGENERATIONS. 

Amyloid  Degeneration. — Amyloid  degeneration  is  a  process  as  a  result 
of  which  there  is  found  in  various  tissues,  especially  in  the  walls  of  the 
smaller  blood-vessels,  a  firm,  colorless,  translucent  substance.  Whether 
this  substance  is  formed  by  a  degeneration  of  the  tissues  themselves 
or  is  merely  deposited  in  them  has  not  yet  been  determined.  The  amy- 
loid substance  is  composed  of  carbon,  hydrogen,  nitrogen,  and  sulphur, 
and  some  investigators  have  referred  its  formation  to  a  union  of  chon- 
dratin-sulphuric  acid  and  a  proteid,  a  combination  which  is  rendered 
possible  by  the  normal  presence  of  chondratinic  acid  in  bone,  cartilage, 
and  elastic  tissue.  The  liver,  spleen,  kidneys,  intestines,  and  lymph- 
glands  are  the  most  frequent  locations  of  the  degeneration,  which  begins 
generally  in  the  middle  coat  of  the  smaller  arteries,  but  sometimes  in 
the  trabecula  of  the  lymph-nodes.  It  rarely  involves  connective 
tissue  elsewhere.  It  may  occur  in  the  larger  blood-vessels,  in  the  heart, 
or  in  the  mucous  membranes  of  the  respiratory  passages.  Few  or  many 
parts  are  simultaneously  involved  in  difterent  cases. 

The  organs  affected  by  it  are  markedly  enlarged  and  much  increased 
in  firmness.  Their  color  is  usually  pale,  though  this  may  be  altered  by 
the  presence  of  other  degenerations  or  by  pigmentation. 

Causes. — It  results  from  wasting  diseases,  particularly  from  sup- 
puration and  ulceration,  more  especially  when  these  involve  bone,  and 


24  PRACTICE  OF  MEDICINE 

yet  more  certainly  when  the  disease  is  of  tuberculous  or  syphilitic  origin. 
It  is  rarely  encountered  in  the  absence  of  any  of  these  influences,  as  a 
result  of  mixed  infection,  severe  malarial  infection,  dysentery,  leukemia, 
and  in  cachectic  conditions. 

Results. — A  moderate  degree  of  amyloid  degeneration  does  not  im- 
mediately jeopardize  life,  but  recovery  never  occurs.  The  individual  is 
always  anemic  and  has  a  peculiar  waxy,  cachectic  appearance.  The  local 
impairment  of  function  corresponds  to  the  degree  of  degeneration. 

Mucoid  degeneration  affects  the  cells  or  intercellular  tissue  and  pro- 
duces a  semifluid,  translucent  substance  containing  mucin. 

Its  occurrence  may  denote  only  an  increased  functional  activity  of 
the  cells,  as  in  catarrh ;  but  in  many  instances,  more  truly  pathological, 
the  mucin  formation  appears  to  be  entirely  in  the  intercellular  substance. 
It  is  generally  found  in  the  subcutaneous  tissue  in  myxedema  and  scle- 
roderma, and  it  is  a  common  degeneration  in  neoplasms.  It  may  affect 
also  cartilage,  bone,  and  other  tissues.  The  cells  and  tissues  aff'ected 
may  be  entirely  destroyed.  When  only  the  intercellular  substance  is 
involved,  the  cells  may  be  destroyed  as  a  result  of  compression. 

Colloid  degeneration  is  closely  related  to  mucoid,  but  the  substance 
produced  is  not  the  same.  It  resembles  rather  the  colloid  matter  of 
the  thyroid  gland.  It  is  usually  confined  to  the  cells  and  aff'ects  the 
intercellular  substance  only  by  inducing  atrophic  changes.  It  may 
involve  the  cell  but  partially,  or  it  may  entirely  replace  the  protoplasm 
and  cause  its  rupture.  It  occurs  in  goiter  and  neoplasms  of  the  thyroid 
gland,  in  the  kidneys  and  adrenals,  the  prostate  and  seminal  vesicles; 
but  very  seldom  in  tumors  elsewhere  than  in  the  thyroid.  Colloid 
matter  may  be  transformed  into  mucoid  or  hyalin,  and  mucoid  mat- 
ter may  be  converted  into  colloid.  The  colloid  substance  may  undergo 
solution  in  the  products  of  serous  transudation,  leaving  cysts  filled 
with  a  brownish  fluid  often  containing  blood,  pus,  and  cholesterin 
crystals. 

Hyalin  degeneration  (waxy  or  vitreous  degeneration)  resembles 
amyloid  except  in  the  character  of  the  substance  produced.  The  hyalin 
deposits  are  generally  in  the  form  of  sharply  defined,  round  or  oval, 
rarely  bottle-shaped  bodies.  The  nature  of  the  process  is  unknown. 
Some  investigators  refer  to  mesoblastic,  epithelial,  or  blood  hyalin, 
referring  the  origin  of  the  hyalin  matter  to  one  or  other  of  these  tissues. 
It  is  generally  found  in  the  smaller  blood-vessels  in  old  age,  following 
prolonged  fever,  or  as  a  result  of  arteriosclerosis;  in  the  brain,  lymph- 
glands,  ovaries,  renal  tubules,  and  voluntary  muscles  (Zenker's  degenera- 
tion); in  the  walls  of  aneurisms,  in  the  lesions  of  tuberculosis  and 
syphilis,  and  in  the  retina  and  choroid  coats  of  the  eye.  It  has  been 
observed  also  in  leucocytes.  Wood-plates,  and  fibrin.  It  is  probably  a 
feature  in  coagulation  necrosis.  It  is  caused  by  infection  and  intoxica- 
tion, especially  by  lead-poisoning. 

Glycogenic  degeneration  is  a  condition  in  which  clear,  globular  masses 
of  glycogen  are  formed  in  cells  where  this  substance  is  not  present,  or 
in  abnormal  quantity  where  its  presence  is  normal,  as  in  the  liver, 
cartilage,  and  muscle.  The  glycogen  bodies  are  closely  allied  to  the 
amylaceous  bodies  of  the  prostate,  and  resemble  amyloid  bodies  in  ap- 
pearance except  that  they  may  be  concentrically  striated.    The  degenera- 


RETROGRADE  PROCESSES  25 

tion  occurs  especially  in  diabetes.    It  sometimes  involves  leucocytes,  pus- 
cells,  and  various  tumor  structures  of  mesoblastic  origin. 

Dropsical  infiltration  is  a  term  applied  to  a  condition  in  which  the 
cells  become  edematous.  In  ordinary 
dropsy  the  fluid  accumulates  in  the 
intercellular  spaces,  and  the  cells  are 
affected  only  by  compression.  It 
occurs  for  the  most  part  as  a  re- 
sult of  cloudy  swelling  or  in  such 
conditions  as  burns,  pemphigus,  and 
other  vesicular  diseases  of  the  skin, 
and  probably  in  erythema  nodosum, 
urticaria,  herpes,  and  other  nervous 
affections.  The  cells  are  much  en- 
larged and  may  rupture.  The  pro- 
toplasm is  compressed  and  is  con- 
sequently liable  to  undergo  fatty  Fig.  4.— Transverse  section  of  a  bun- 
degeneration                                                           ^^^  '-'^  muscular  fibers  in  a  state  of  h)'- 

Calcification  consists  of  a  deposit       '^'X'  defeneration      '^/Muscular  fibers 

.  .  ^  with  small  drops  of  fluid;    o.  Fibers  with 

of    the    earthy    salts    m    the    tissues,       large     drops.       (The    preparation     was 

especially    the    carbonate    and    phos-       hardened   in  Muller's  fluid,  then   stained 

phate  of  hme.      It  is  purely  a  passive       ^^'ith   hematoxylin,  and  finally  mounted 

•    r-i,       .  •  ]•   4.-  •   I-         in  Canada  balsam.     Maernified  66  diam- 

process,  an  mnltration  as  distmguish-       ^     n     ^v    1     n  '^ 

A  c  A  *-•  T^-  n  eters).     (Ziegler.) 

ed  from  a  degeneration.     It  usually 

occurs  in  tissues  that  are  dead  or  in  a  state  of  advanced  fatty,  h3^alin, 

or  other  degeneration.     Deficient   nutrition  is  an  important  factor  in 

predisposing  to  the  infiltration.    In  some  conditions,  as  in  old  age  and 

after  extensive  necrosis  of  bone,  it  is  attributed  by  some  writers  to  an 

abnormal  accumulation  of  lime  within  the  system.    It  is  believed  that 

the  salts,  as  a  rule,  are  simply  deposited  in  the  tissues,  although  it  has 

been    suggested  that  they,   perhaps,   form  combinations  with    proteids 

and  fatty  acids.    And  another  theory  holds  that  soluble  salts  become 

insoluble  within  the  tissues.     In  psammomata  the  salts  are  probably 

deposited  in  hyalin  matter  previously  formed. 

The  infiltration  usually  occurs  first  in  the  form  of  fine  granules 
scattered  throughout  the  intercellular  substance,  but  it  may  later  invade 
the  cells.  It  generally  forms  irregular  spherical  bodies  showing  concen- 
tric striations,  but  in  the  blood-vessels  it  often  assumes  the  form  of 
plates.  It  also  forms  incrustations  around  foreign  bodies  and  in  the 
walls  of  cysts.  In  neoplasms  so  great  an  extent  of  tissue  may  be 
involved  as  to  produce  large  masses  of  mortar-like  matter  or  large, 
irregular,  solid  concretions. 

The  most  serious  consequences  of  calcification  are  met  with  in  the 
heart  and  blood-vessels,  especially  in  sclerotic  endocarditis  of  the  valves 
and  in  arteriosclerosis.  The  aorta,  coronary  artery,  and  the  vessels 
of  the  brain  are  common  seats  of  calcification.  As  a  rule  it  affects 
the  middle  and  internal  coats  of  the  vessels.  In  the  pericardium  it 
follows  inflammations,  and,  after  the  obliterative  form,  it  sometimes 
incloses  the  heart  in  a  calcareous  sheath.  Calcification  sometimes  as- 
sumes the  magnitude  of  an  almost  universal  invasion  of  the  body.  The 
nonvascular  neoplasms  are  especially  liable  to  calcareous  infiltration, 


26 


PRACTICE  OF  MEDICINE 


but  it  is  found  also  in  sarcomata.  The  gall-bladder  and  urinary  blad- 
der, the  walls  of  cysts,  old  abscesses,  hematomata,  thrombi,  cicatrices, 
dead  ganglion  cells,  dead  epithelium  like  that  of  the  kidney  tubes,  espe- 
cially after  mercurial  poisoning,  and  dead  parasites  are  often  infiltrated. 
The  occurrence  of  the  infiltration  in  the  form  of  brain-sand  and  as  a 
senile  change  in  the  vessels  and  cartilages  is  not  regarded  as  patho- 
logical. 

Results. — The  deposit  of  a  small  amount  of  calcareous  matter  in 
a  region  does  not  necessarily  destroy  its  vitality,  but  complete  cal- 
cification denotes  the  death  of  the  tissue,  and  no  restoration  is  pos- 
sible. 

Pigmentation  consists  in  the  formation  or  deposit  within  the  tissues 
of  substances  which  give  them  an  abnormal  color.  There  are  four 
varieties,  based  upon  the  origin  of  the  pigment.  These  are  termed  meta- 
bolic, hematogenous,  hepatogenous,  and  extraneous. 

1.  Metabolic  pigmentation  is  due  to  cellular  activity.  It  is  illus- 
trated in  freckles  and  some  of  the  skin  diseases,  possibly  also  in  the 
melanotic  sarcoma.  It  occurs  in  Addison's  disease,  in  some  cases  of 
diabetes,  and  in  the  anemias  and  cachexias.  The  pigment  is  doubtless 
derived  from  the  hemoglobin  of  the  blood,  but  the  mode  of  its  forma- 
tion is  not  known.  It  may  be  deposited  within  the  cells  or  between 
them,  in  the  form  of  granules,  rarely  as  crystals. 

2.  He7natogenous  pigmentation,  in  which  the  pigment  is  derived  from 
the  hemoglobin,  is  divided  into  two  classes  :  («-)  Siderous,  from  iron- 
containing  pigment,  and  (Ji)  nonsiderous,  free  from  iron.  The  chief 
siderous  pigments  are  hemosiderin  and  its  modifications;  the  nonside- 
rous pigments  are  various  derivatives  of  hematin.  It  is  possible  that 
the  latter  modifications  are  the  result  of  cellular  activity.  There  are 
two  groups  of  siderous  pigmentation,  one  in  which  the  pigments  are 
set  free  in  the  blood,  the  other  in  which  they  are  deposited  in  the  tissues. 
In  malaria,  pernicious  anemia,  and  certain  infectious  and  septic  processes, 
we  see  examples  of  the  former;  and  in  bruises  and  the  diffusion  of  pig- 
ment from  thrombi  and  in- 
terstitial hemorrhage,  ex- 
amples of  the  latter  form. 

3.  Hepatogetwiis  pigment 
is  derived  from  bilirubin  or 
biliverdin.  These  are  depos- 
ited in  solution,  granules, 
or  crystals  in  almost  every 
tissue  except  the  brain,  and 
especially  in  the  liver,  skin, 
mucous  membranes,  and 
glands. 

4.  Extraneous  pigmenta- 
tion occurs  principally  in  the 
respiratory  passages  and  is 
generally  called    pneumono- 

koniosis.  It  results  from  the  inhalation  of  minute  particles  of  stone 
(calcicosis),  iron  (siderosis),  or  coal  (anthracosis).  The  pigments  are 
deposited  in  the  submucosa  of  the  bronchi  and  in  the  fibrous  tissue  of 


Fig.  5.— Hemosiderin  in  liver-cells  (rt).   b.  Fatty 
degeneration  of  cells  (osmic-acid  stain).    (Ziegler,) 


NECROSIS  27 

the  lungs,  or  they  may  be  carried  to  the  tracheobronchial  and  medi- 
astinal glands.  They  rarely  pass  into  the  circulation  and  are  carried 
to  the  liver,  spleen,  kidneys,  and  elsewhere. 

Argyria  is  a  form  of  pigmentation  which  results  from  the  ingestion 
of  soluble  silver  salts  and  affects  especially  the  skin,  gastric  and  intestinal 
mucous  membranes,  the  liver  and  kidneys. 


NECROSIS. 

By  necrosis  is  meant  the  death  of  a  tissue.  Death  of  cells  is  termed 
necrobiosis ;  that  of  an  entire  part,  gangrene.  The  latter  term  is  applied 
also  to  a  putrefactive  change  in  necrotic  tissues  of  any  kind. 

Causes. — The  different  forms  of  necrosis  are  caused:  (i)  By  insuf- 
ficient nutrition,  especially  by  complete  interruption  of  the  blood 
supply;  (2)  by  the  toxic  products  of  bacteria  or  chemical  agents ;  (3) 
by  mechanical  injury;  or  (4)  by  trophic  disturbances. 

1.  Profound  local  anemia,  however  it  may  have  been  produced,  is 
capable  of  causing  necrosis;  venous  stasis,  especially  that  produced  by 
mechanical  obstruction  or  chemical  agents,  may  be  its  cause.  Senility, 
general  anemia,  cachexia,  abnormal  metabolism  and  its  products,  are 
among  the  special  predisposing  causes. 

2.  The  toxic  products  of  the  bacteria  are  often  the  immediate  cause 
of  necrosis;  heat,  cold,  the  alkaloids,  metallic  salts,  acids,  alkalis,  and 
many  other  substances  act  in  the  same  manner,  producing  it  either 
directly  or  indirectly  by  first  causing  various  degenerations.  Inflam- 
mation may  lead  to  necrosis,  and  on  the  other  hand  necrosis  almost 
invariably  incites  inflammation  in  the  surrounding  tissues. 

3.  Chief  among  mechanical  injuries  is  pressure  which  acts  directly 
upon  the  tissue,  or  indirectly  by  causing  circulatory  disturbance,  as  for 
example,  in  the  pressure  of  neoplasms,  calculi,  and  other  concretions  or 
exudations. 

4.  Trophic  disturbances  are  not  regarded  by  all  authorities  as  opera- 
tive in  the  production  of  necrosis.  Many  attribute  to  disturbance  of 
nutrition  or  pressure  a  class  which  Stengel  and  others  maintain  are 
due  to  a  disturbance  of  the  biological  mechanism  of  the  cells.  Among 
the  examples  of  this  character  are  bedsores,  the  skin  lesions  sometimes 
accompanying  trigeminal  neuritis,  and  various  arthropathies. 

Varieiies. — Several  distinct  forms  of  necrosis  are  recognized,  chief 
among  them:  (i)  Coagulation  necrosis,  (2)  liquefaction  necrosis,  and 
(3)  fat  necrosis. 

I .  Coagulation  necrosis  is  a  peculiar  form  of  tissue  death  in  which, 
through  a  process  resembling  coagulation,  the  cell  contents  are  replaced 
by  a  hyalin-like  substance.  The  process  is  supposed  to  be  a  species  of 
fibrin-formation. 

Causes. — Among  the  causes  that  are  especially  likely  to  produce  this 
form  of  necrosis  are  the  toxic  effects  of  the  pus-forming  bacteria,  and 
the  bacilli  of  tuberculosis  and  diphtheria.  Coagulation  necrosis  often 
occurs  in  the  products  of  exudation  or  transudation. 

Results. — A  tissue  that  has  undergone  coagulation  necrosis  loses 
its  function.     The  necrotic  mass  may  be  separated  by  ulceration  and  cast 


28 


PRACTICE  OF  MEDICINE 


Fig.  6. — Tubercular  caseation. 
a,  Granular,  cheesy  material,  b,  Fi- 
brocellular  tissue,  c,  Degenerated 
giant-cells  with  bacilli.     (Ziegler.) 


off;  it  may  undergo  caseation,  liquefaction,  or  suppuration,  or  it 
may  be  removed  by  absorption  and  its  place  filled  with  cicatricial 
tissue. 

2.  Caseation  is  a  term  applied  to  coagulation  necrosis  when  the 
result  is  a  mass  resembling  cheese,  but  less  homogeneous  and  more 
granular.  It  occurs  especially  as  a  result  of  tuberculosis,  but  may  oc- 
cur in  other  granulomata,  especially  those  of  syphilitic  origki  or  as 
a  result  of  other  processes,  as  in  the  liquefaction  necrosis  of  the  central 
nervous  system.   The  results  are  the  same  as  those  of  coagulation  necrosis. 

3.  Liquefaction  Necrosis.— In  this 
form  of  tissue  death,  the  product  is 
liquefied.  It  may  occur  as  a  primary 
process,  or  it  may  be  secondary  to  in- 
flammation, the  other  forms  of  ne- 
crosis, the  degenerations,  or  gangrene. 
The  necrotic  mass  varies  in  consistency 
with  the  duration  of  the  process,  and 
with  the  character  of  the  tissue  af- 
fected, and  in  color  from  white  to  a 
dark  brown. 

4,  Fat  necrosis  is  a  form  which  af- 
fects the  fatty  tissues.  Its  occurrence 
is  limited  almost  exclusively  to  the  sub- 
peritoneal cellular  tissues  and  the  fat 

of  the  abdominal  walls,  and  it  usually  results  from  disease  of  the  pan- 
creas. The  necrotic  areas  are  small,  white,  and  soft,  but  frequently 
become  gritty  from  deposit  of  lime  salts.  It  is  attributed  to  the  action 
of  steapsin,  the  pancreatic  fat-splitting  ferment. 

5.  Gangrene  is  a  putrefactive  necrosis.  The  term  has  generally  been 
used  to  designate  the  death  of  an  entire  tissue  or  member  or  of  exten- 
sive areas.  It  may  be  primary,  but  is  more  frequently  secondary  to 
other  forms  of  necrosis. 

Causes. — The  predisposing  cause  of  gangrene  may  be  an  injury  of 
any  kind — mechanical,  chemical,  electric — or  an  arrest  of  circulation  in 
the  area,  as  by  a  thrombus  or  embolus.  The  immediate  cause  is  an 
invasion  of  the  tissues  by  micro-organisms,  for  the  most  part  by  sapro- 
phytic bacteria.  Several  different  microbes  have  been  found  capable  of 
producing  primary  gangrene. 

Forms.— There  are  two  principal  forms  of  gangrene,  designated  dry 
and  moist,  from  the  character  of  the  necrotic  tissue  produced. 

(ar)  I?ry  gang7-ene  occurs  most  frequently  as  a  result  of  arterial  ob- 
struction in  regions  having  insufficient  collateral  circulation  to  maintain 
their  vitality.  It  occurs  in  senility,  Raynaud's  disease,  ergotism,  throm- 
bosis or  embohsm,  or  as  a  subsequent  change  in  moist  gangrene.  The 
tissue  becomes  opaque  and  finally  black;  it  is  generally  completely 
mummified,  and  may  be  very  slow  to  separate. 

(^)  Moist  gangroie  is  more  frequently  a  result  of  the  closure  of  a 
large  vein  as  by  the  pressure  of  tumors,  or  cicatricial  bands,  or  by 
torsion  or  swelling,  as  in  intussusception  and  other  strangulations, 
floating  kidney,  etc.  In  the  lung  it  may  develop  after  thrombosis  or 
embohsm  of  the  pulmonary  arteries  or  veins,  bronchiectasis,  abscess,  or 


INFLAMMATION  .     2^ 

pneumonia.  It  sometimes  affects  the  extremities  in  diabetes,  and  occurs 
as  a  primary  affection,  probably  as  a  result  of  the  action  of  a  specific 
bacillus,  in  noma.  The  tissue  affected  becomes  dark  brown  and  soft, 
and  in  most  instances  it  is  ultimately  liquefied.  The  tissues  often  become 
emphysematous,  owing  to  the  liberation  of  gas  by  the  bacteria.  The 
necrotic  mass  may  be  separated  from  the  surrounding  healthy  tissue  by 
an  area  of  inflammation  (the  line  of  demarcation) ;  it  is  always  sur- 
rounded by  an  area  of  coagulation  necrosis  of  variable  extent.  The 
gangrenous  mass  is  often  cast  off  a,s  a  slough,  or  sphacelus;  it  may 
become  encysted,  or  converted  into  a  dry  gangrene  and  undergo  very 
slow  separation.  Hemorrhage  sometimes  follows  the  rupture  of  vessels 
in  the  surrounding  tissues.    A  fatal  toxemia  is  not  infrequently  induced. 

INFLAMMATION. 

Inflammation  is  a  complex  process  of  a  degenerative,  proliferative,  and 
regenerative  character,  affecting  the  blood-vessels  and  tissues  as  a  result 
of  injury.  The  causes  may  be  mechanical,  bacterial,  or  thermal — any 
agent,  in  fact,  which  is  capable  of  producing  strong  irritation  without 
occasioning  the  complete  necrosis  of  the  tissues  affected.  It  has  been 
defined  as  the  response  of  living  tissue  to  injury. 

The  process  is  probably  nearly  or  quite  the  same  in  all  instances. 
The  phenomena  generally  described  as  occurring  in  experimentally 
induced  inflammation  are:  (i)  A  transitory  contraction  of  the  arteries 
which  may  be  of  so  short  duration  as  to  escape  observation.  This  is 
still  referred  by  some  investigators  to  the  action  of  the  vasomotor 
nerves,  while  by  others  it  is  looked  upon  as  a  result  of  degenerative 
changes  in  the  vessel-walls.  (2)  A  dilatation  of  the  arteries,  then  of  the 
capillaries  and  veins.  (3)  Following  this,  an  exudation  or  transudation 
of  the  corpuscles  and  plasma  with  other  changes  to  be  more  fully  de- 
scribed. 

The  blood  at  first  flows  more  rapidly,  then  more  slowly,  and  finally 
may  stop,  especially  in  the  capillaries  of  the  central  zone  of  the  inflamed 
area.  As  the  blood-current  becomes  slower  the  leucocytes  in  the  plasmic 
zone  of  the  vessels  become  more  numerous  and  adhere  to  the  sides  in  a 
row.  In  a  capillary,  a  cluster  of  leucocytes  frequently  alternates  in 
passage  with  clusters  of  red  corpuscles  or  of  red  and  white  in  normal 
ratio. 

The  migration  of  the  leucocytes  is  abnormal  only  in  the  excessive 
numbers  passing  into  the  tissues.  Large  numbers  of  red  blood-cells 
soon  follow,  accompanied  by  highly  coagulable  plasma  rich  in  albumin. 
The  activity  of  the  leucocytes  has  been  attributed  to  irritant  substances 
possessing  an  attraction  for  the  leucocytes  (chemosis).  These  irritant 
substances  are  supposed  to  be  set  free  by  the  destruction  of  cells  in 
traumatic  inflammations,  or  to  be  derived  from  the  toxic  substance 
which  induces  the  inflammation.  The  escape  of  the  red  corpuscles  and 
plasma  is  regarded  as  purely  mechanical,  a  result  of  the  blood  pressure 
within  the  vessels. 

In  the  connective  tissue  about  the  vessels  a  proliferation  is  set  up 
leading  to  karyokinesis  and  the  formation  of  small  round  cells  (round- 
cell  infiltration).    The  new  cells  are  formed,  in  part  at  least,  from  the 


3° 


PRACTICE  OF  MEDICINE 


cells  of  original  connective  tissue.  The  changes  in  the  tissues  are  at 
first  degenerative  in  character;  later  they  become  proliferative.  The 
degenerations,  cloudy  swelhng,  fatty,  mucoid,  even  necrosis,  affect  pri- 
marily the  walls  of  the  blood-vessels  or  the  connective  tissues  about 
them.  The  proliferation  of  connective  tissue  produces  small  round  for- 
mative cells,  larger  than  leucocytes  and  having  large,  round  or  oval, 
pale  nuclei,  which  often  show  karyokinesis.  The  same  form  of  prolifer- 
ation is  sometimes  seen  in  parenchymatous  cells. 

Ziegler  describes,  among  others,  the  following  forms  of  inflammation, 
basing  the  distinctions  between  them  upon  the  character  of  the  exudates 
belonging  to  each,  and  the  changes  which  they  subsequently  undergo, 
rather  than  upon  any  essential  difference  in  the  process  : 

1 .  Serous  inflammation  is  characterized  by  a  fluid  exudate  containing 
comparatively  few  cellular  elements.  When  affecting  the  skin  or  sub- 
cutaneous cellular  tissue,  it  is  called  inflammatory  edema.  It  affects 
also  the  mucous  membranes,  serous  sacs,  parenchyroa  of  the  kidney  and 
other  organs.     The  fluid  is  rich  in  albumin  and  fibrin  factors. 

2.  Fibrinous  inflammation  is  characterized  by  immediate  coagula- 
tion with  the  production  of  fibrin.  It  occurs  especially  upon  serous 
and  mucous  surfaces,  after  desquamation  of  the  epithelium,  and  forms 
whitish,  more  or  less  adherent  membranes.  It  sometimes  forms  usider 
the  epithelium,  or  spreads  over  the  epithehal  covering,  of  adjacent 
areas. 

3.  Hemorrhagic  inflammation  is  usually  associated  with  the  fibrinous 
form,  as  in  fibrinous  pneumonia.  It  differs  from  that  form  of  inflamma- 
tion only  in  the  greater  number  of  red  blood-cells  that  are  present. 
Hemorrhagic  inflammation  occurs  also  in  the  central  nervous  system, 

kidneys,  lymph-glands,  and 
skin.  Hemorrhage  into  an 
inflamed  area  is  to  be  ex- 
cluded from  this  class. 

4.  Purulent  or  suppura- 
tive inflammation  is  gener- 
ally a  result  of  infection  by 
pyogenic  micro-organisms, 
iDut  may  be  produced  by  a 
number  of  chemical  irritants 
in  the  absence  of  bacteria,  or 
by  bacteria  which  are  not  or- 
dinarily regarded  as  pyo- 
genic, as  the  typhoid  and 
colon  bacilli.  It  is  often  a 
result  of  bacterial  infection 
^  r.     ■        r        I       f.      J-  u^-i     V    ^„      of  an  area  involved  in  an- 

FiG.   7.— Section   of   uvula   after  diphtheritic  de-  ,        ^  r  •    n 

struction  of  its  epithelial  covering,     a,   Micrococci.  Other  form  of  mflammation. 

b,    Mucous    membrane,    infiltrated     and    broken  When    the    suppuration     OC- 

down.      c,    Small-celled    infiltration,     d,    Fibrinous  ^^-^^  \^  |-}^g  midst  of  a  tissue 

exudate.  ^^  organ,  it  constitutes  an. 

abscess ;  when  it  causes  destruction  of  the  surface  of  the  skin  or  of  a  mu- 
cous membrane, it  is  an  ulcer;  when  confined  to  the  substance  of  the  skin, 
it  is  a  furuncle.    When  the  micro-organisms  enter  the  blood  they  produce. 


REGENERATION  31 

pyemia;  when  only  the  toxins  are  absorbed  into  the  circulation,  a  con- 
dition of  septicemia,  or  sepsis,  is  produced. 

5.  Diphtheritic  inflammation  occurs,  not  only  in  diphtheria  infection, 
but  as  a  result  of  other  infections,  or  of  the  action  of  a  chemical  irritant 
for  the  most  part  upon  a  mucous  membrane.  It  is  characterized  by  a 
coagulation  of  the  exudate  and  coagulation  necrosis  of  the  cells  of  the 
inflamed  area.  The  exudate  consists,  as  a  rule,  of  coagulated  fibrin  in- 
closing degenerated  cells  and  bacteria.  The  exudate  of  true  diphtheria 
is  distinguished  by  the  predominance  of  the  Klebs-Loffler  bacillus,  that  of 
croupous  pneumonia  by  the  fibrin  and  pneumococci. 

6.  Necrotic  inflammation  is  a  form  in  which  infection  has  been  in- 
duced by  gas-forming  bacteria,  producing  putrid  necrosis  of  the  tissues. 

Terminaiion  of  Inflammation. — Inflammatory  processes  terminate  :  («:) 
By  delitescence,  a  sudden,  early  cessation,  with  rapid  restoration  of 
integrity;  (^b^  by  resolution,  a  slower  return  to  the  normal  condition; 
or  ((t)  by  the  development  of  degenerations  or  necrosis. 

7.  Chronic  Inflammation, — This  term  is  used  to  describe,  not  only 
inflammations  of  long  duration,  due  either  to  slow  progress  or  a  con- 
tinuation of  the  causal  irritation,  but  more  particularly  with  reference 
to  their  results.  When  the  process  involves  the  proliferation  and  repro- 
duction of  connective  tissues,  it  is  sometimes  spoken  of  as  interstitial 
inflammation.  It  generally  results  in  induration  and  contraction  of  the 
tissues,  as  in  the  scleroses  of  the  liver,  kidneys,  and  other  organs.  \^Tien 
on  or  near  the  surface,  it  forms  bands  of  adhesion  between  adjacent 
structures. 

REGENERATION. 

Regeneration  is  a  reparative  process  by  which  new  cells  and  tissues 
are  formed  to  replace  those  that  have  been  destroyed.  It  ma)-  be  nor- 
mal or  pathological  in  character.  Normal  regeneration  is  constantly 
going  on  in  the  body  for  the  restoration  of  cells  that  have  been  consumed 
in  the  vital  processes.  So  far  as  it  is  understood,  normal  or  physio- 
logical regeneration  consists  in  a  proliferation  of  cells  without  other 
changes. 

Pathological  regeneration  produces  cells  and  tissues  to  replace  those 
lost  as  a  result  of  disease  or  injury,  but  the  new-formed  cells  and  tissues 
are  not  always  of  the  same  type  as  those  which  they  replace.  The  cause 
and  limitation  of  the  process  probably  lie  in  the  inherent  tendency  of 
cells  to  proliferate,  but  we  do  not  know  why  it  is  developed  or  by  what 
influence  it  is  ordinarily  arrested  when  the  proper  limit  has  been  reached. 
Some  authors  regard  the  process  as  a  part  of  inflammation,  but  in  most 
instances  the  tissue  changes  are  quite  distinct  from  those  of  inflam- 
mation. 

The  new  tissue  consists  at  first  of  new  blood-vessels,  loops  formed 
by  a  process  of  budding  from  the  old  vessels,  surrounded  by  embry- 
onic tissue  formed  in  part  from  leucocytes  and  in  part,  by  proliferation, 
from  the  connective  tissue  cells.  Cell-proliferation  alone  is  capable  of 
restoring  lost  surface  epithelium.  In  the  regeneration  of  connective  tis- 
sue there  occur  an  enlargement  and  elongation  of  the  original  round 
formative  cells  into  fibroblasts,  which,  together  with  the  homogeneous 


32  PRACTICE  OF  MEDICINE 

intercellular  substance,  undergo  fibrillation,  through  a  process  of  cleav- 
age. In  the  regeneration  of  muscular  tissue  the  original  formative 
cells  are  designated  sarcoblasts;  in  that  of  cartilage,  chondroblasts; 
in  that  of  bone,  osteoblasts.  The  subsequent  changes  in  the  cells  are 
not,  however,  identical  with  those  in  the  regeneration  of  connective  tis- 
sue. In  some  instances,  too,  the  regeneration  of  these  tissues  occurs 
by  a  direct  growth  from  the  pre-existing  cells  of  the  same  type ;  less  fre- 
quently from  those  of  another  type  (metaplasia). 

In  the  repair  of  lesions  in  glandular  organs,  the  normal  tissues  of 
the  organ  are  to  a  greater  or  less  extent  reproduced,  generally,  however, 
in  an  atypical  form,  the  new  tissue  remaining  imperfect ;  but  the  greater 
part  of  the  destroyed  tissue,  as  a  rule,  is  replaced  by  new  fibrous  connec- 
tive tissue.  In  some  instances  the  new,  atypical  formation  is  exuberant 
and  results  in  the  formation  of  adenomatous  tissue. 

THE  BACTERIA  OF  DISEASE. 

General  Bacteriology. — Bacteria  are  the  smallest,  and  in  structure 
the  simplest,  members  of  the  vegetable  kingdom.  From  their  resem- 
blance to  the  fungi,  and  from  the  fact  that  they  are  reproduced  for  the 
most  part  by  transverse  division,  they  are  sometimes  referred  to  as 
fission-fungi,  or  schizomycetes.  Their  size  is  measured  in  micromillimeters 
(designated  ,a).  They  receive  their  nutriment  by  direct  absorption  of 
soluble  living  or  dead  matter;  but,  being  devoid  of  chlorophyll,  they 
are  unable  to  decompose  substances  into  their  simpler  elements  suitable 
for  absorption.  From  the  character  of  the  nourishment  they  are  able 
to  appropriate,  bacteria  are  divided  into  two  major  classes,  the  sapro- 
phytes and  the  parasites.  The  former  are  the  more  numerous  and  live 
upon  dead  organic  matter;  the  latter  live  upon  or  within  some  other 
living  organism  and  receive  from  it  their  nutrition.  But  there  are  some 
members  of  each  class  that  are  able  to  adapt  themselves  to  the  con- 
ditions of  the  other ;  parasites  that  can  for  a  time  live  upon  dead  mat- 
ter, and  saprophytes  that  can  exist  as  parasites.  These  are  called 
facultative  parasites  and  saprophytes.  The  saprophytes  are  for  the  most 
part  harmless  to  man;  they  are  often,  indeed,  beneficial,  in  so  far  as 
they  consume  dead  animal  and  vegetable  matter. 

Structure. — A  bacterium  consists  of  a  cell  believed  to  have  a  cell  mem- 
brane, not  always  clearly  defined,  within  which  is  a  protoplasmic  layer 
and  a  central  fluid.  No  nucleus  has  yet  been  discovered.  The  interior 
of  the  cell  is  generally  homogeneous,  but  occasionally  it  appears  granu- 
lar, as  is  the  case  with  the  diphtheria  bacillus  under  the  action  of  suitable 
stains.  Babes  named  these  granules  metachromatic  bodies,  but  Ernst 
regards  them  as  sporagenous  granules. 

Mo7-phology. — All  micro-organisms  fall  under  one  of  three  classes  when 
compared  with  reference  to  their  form.  The  first  class  consists  of  the 
micrococci,  spherical  in  form;  the  second,  bacilH,  rod-shaped;  the  third, 
spirilla,  shaped  like  a  spiral :  and  the  members  of  each  group  are  capa- 
ble of  reproducing  bacteria  only  after  their  kind.  The  cocci  multiply 
chiefly  by  transverse  division;  sometimes  by  division  in  two  or  more 
planes;  sometimes  they  divide  irregularly.  The  bacilli  and  spirilla  mul- 
tiply almost  entirely  by  transverse  division,  but  occasionally,  perhaps, 


BACTERIOLOGY  ^^ 

by  the  formation  of  spores.  The  form  of  the  micro-organism  under- 
goes considerable  change  in  the  process  of  division.  The  spherical  coccus, 
as  a  rule,  becomes  enlarged  and  oval,  and  division  into  two  cells  gives 
each  half  a  more  or  less  perfect  semilunar  shape.  When  more  than  one 
division  occurs,  the  young  cocci  have  the  appearance  of  imperfect 
spheres ;  they  are  sometimes  lanceolate  or  biscuit-shaped.  A  short  bacil- 
lus produces  two  nearly"  round  or  square  cells;  sometimes,  indeed,  the 
short  diameter  may  be  distinguished  with  difficulty  from  the  long. 

The  mature  micrococci  vary  in  diameter  from  0.3//.  to  3//.;  those  of 
the  same  species  are  generally  of  uniform  size.  They  occur  singly,  in 
pairs  (diplococci),  in  chains  (streptococci),  in  groups  of  four  (tetrads), 
in  cubes  (sarcina),  and  in  irregular  grape-like  clusters  (staphylococci). 

Bacilli  may  be  compared,  when  mature,  to  minute  cylinders  whose 
longitudinal  and  transverse  diameters  are  never  equal.  They  vary  in 
length  from  0.2a  to  30//  and  in  width  from  o.i,a  to  4;/.  The  largest 
pathogenic  bacilli  do  not  average  more  than  3,a  in  diameter.  It  is  cus- 
tomary to  speak  of  a  bacillus  as  being  slender  when  the  ratio  of  its 
length  to  its  width  is  from  4:1  to  10:1,  and  as  thick  when  the 
ratio  is  about  2:1.  The  typical  bacillus  is  straight,  uniform  in  diameter, 
with  flat  ends,  but  many  of  the  more  slender  forms  are  bent,  as  is  oc- 
casionally seen  in  the  tubercle  bacillus.  Others,  as  the  bacillvis  of  diph- 
theria, are  not  of  uniform  thickness,  often  appearing  nodular  or  thicker 
at  one  end.  The  formation  of  spores  also  gives  the  rod  an  irregular 
outline.  A  beaded  appearance  is  often  seen,  also,  which  is  not  due  to 
spore-formation.  Some  forms,  especially  those  endowed  with  the  power 
of  motion,  have  rounded  ends.  Bacilli  occur  singly  or  in  chains  of  greater 
or  less  length;  sometimes  only  two  or  three  remain  united. 

Spirilla  may  be  compared  to  segments  of  a  spiral.  They  occur 
singly,  in  pairs,  or  as  a  continuous  chain  and  have  the  appearance, 
according  to  their  length,  of  a  comma,  an  S,  or  a  complete  spiral.  They 
may  be  slender  or  thick ;  dichotomously  branching  forms  are  also  seen. 

Sporulation. — Reproduction  by  the  formation  of  spores  has  not  been 
determined  to  the  satisfaction  of  all  investigators ;  but  there  seems  to 
be  little  doubt  that  it  is  the  'mode  of  propagation  in  some  species. 
Two  methods  of  sporulation  have  been  described.  In  one  the  spores 
develop  within  the  cell  (endospores) ;  in  the  other  they  produce  a  sprout- 
like separation  of  the  end  of  the  cell.  Spores  are  much  more  tenacious 
of  life  than  is  the  parent  cell,  being  more  resistant  to  the  action  of  many 
harmful  agents.  The  )'Oung  cell  grows  from  one  or  other  surface  of  the 
spore. 

Chemical  Composition. — Bacteria  consist  largely  of  an  albuminous 
matter  which  has  been  called  mycoprotein,  fats,  salts,  and  water.  They 
contain  also  small  quantities  of  extractives.  Cellulose  is  found  in  some 
species,  and  a  gelatinous  carbohydrate,  similar  to  hemicellulose,  in  others. 
The  presence  of  grape-sugar  in  any  species  is  denied  by  Cramer.  Nuclein 
has  been  separated  in  very  minute  quantity,  but  the  nuclein  bases, 
xanthin,  guanin,  and  adenin,  are  more  abundant.  Sulphur  is  found  in 
one  group.  The  quantities  of  the  various  substances  vary  so  widely 
with  the  character  of  the  culture  medium  upon  which  the  bacteria  are 
grown  that  estimates  are  of  little  practical  value. 

Vital  Phenomena. — The  vital  phenomena  of  bacteria   are  of  little  im- 


34  PR.A.CTICE  OF  MEDICINE 

portance  to  us  here,  in  comparison  to  their  chemical  activities.  The 
power  of  motion  possessed  by  some,  the  abihty  to  produce  hght,  heat, 
or  coloring  matter,  acids,  etc.,  interest  us  only  as  means  of  distinguish- 
ing different  species. 

Motility. — A  peculiar,  trembling  motion  may  be  observed  with  the 
microscope  in  all  minute  particles,  whether  living  or  dead.  This  is 
known  as  the  Brownian  movement  and  is  in  no  way  attributable  to 
vitality  when  seen  in  a  micro-organism.  Many  living  bacteria,  however, 
have  a  power  of  independent  motion  which  can  be  readily  seen  when  they 
are  examined  suspended  in  a  drop  of  fluid.  The  movement  varies  from 
a  slow,  undulating,  or  wormlike  creeping  to  a  darting  progression,  so 
quick  that  it  will  not  permit  a  close  examination  of  the  germ.  This 
movement  is  produced  by  means  of  flagella,  fine  hairlike  processes  pro- 
jecting from  the  sides  or  ends  of  the  cell  and  not  unlike  the  cilia  of 
epithelial  cells.  The  character  and  rapidity  of  the  motion  are  to  some 
extent  characteristic  of  the  species,  but  it  depends  to  a  great  degree  upon 
the  culture  medium  and  the  temperature  of  the  fluid  in  which  the  bac- 
teria are  suspended.  Nearly  all  motile  bacteria  are  attracted  by  certain 
substances,  especially  by  pepton  and  urea.  This  attraction  is  known  as 
positive  chemotaxis.  They  are  nearly  all  repelled  by  such  substances 
as  alcohol  and  by  some  of  the  metallic  salts — negative  chemotaxis. 
Many  substances  possess  a  variable  degree  of  chemotaxis,  positive  or 
negative  in  character,  for  one  or  more  species,  which  they  do  not  have 
for  others. 

Chemical  Action. — In  chemical  activity  the  bacteria  are  truly  remark- 
able. I.  Hueppe  gives  us  four  methods  by  which  they  are  able  to  build 
the  chemical  substances  required  for  their  own  nutrition  :  (c/)  Polymeri- 
zation, by  which  a  simple  compound  appears  to  be  doubled;  (^li)  S3'nthe- 
sis,  a  union  of  simple  compounds  into  one  or  more  complex  substances; 
(<;)  the  formation  of  anhydrids,  by  which  new  substances  are  formed 
through  the  abstraction  of  water  from  old  ones;  and  (^)  reduction 
or  the  removal  of  oxygen,  which  is  accomplished  by  the  entrance  of 
hydrogen  into  the  molecule.  They  are  able  also,  through  oxidation, 
hydration,  or  the  overcoming  of  polymerization,  to  convert  bodies  of 
complex  organic  structure  into  simpler  ones. 

2.  One  of  the  most  interesting  features  in  the  vital  phenomena  of 
micro-organisms  is  their  behavior  in  the  presence  or  absence  of  oxygen. 
To  some  the  presence  of  oxygen  is  essential;  to  others  it  is  harmful  or 
destructive.  The  former  group  are  called  aerobes,  the  latter  anaerobes. 
Most  bacteria  are  facultative  in  this  respect,  but  their  products  are  not 
the  same  under  the  two  conditions.  They  produce,  in  the  presence  of 
oxygen,  profound  molecular  changes  in  the  substances  upon  which  they 
act,  which  they  do  not  produce  in  its  absence,  and  the  quantity  of  ma- 
terial disintegrated  is  much  less.  The  products  of  anaerobes  in  the 
presence  of  oxygen  are  frequently  further  decomposed  by  the  aerobes 
and  thus  rendered  inert. 

3.  Fermentation  is  a  process  of  decomposition  of  organic  matter : 
(i)  By  the  direct  action  of  bacteria,  (2)  by  the  substances  contained  in 
the  bacteria  (organized  ferments),  or  (3)  by  chemical  substances  (chemi- 
cal ferments  or  enzymes)  produced  by  the  bacteria  and  capable  of  acting 
independently  of  them  and  without  loss  of  their  own  identity.      Several 


BACTERIOLOGY  35 

processes  are  recognized  as  fermentations  and  named  by  some  observ- 
ers which  are  not  so  regarded  by  others.  Some  authorities  do  not 
recognize  as  fermentation  any  process  which  is  not  attended  with  a 
Uberation  of  gas,  while  others  apply  the  name  to  all  forms  of  decompo- 
sition through  the  action  of  bacteria,  or  to  any  process  developed  by 
a  ferment. 

The  principal  kinds  of  ferments  are  :  (<?)  Proteolytic,  transforming 
albumins  into  simpler,  more  soluble  substances  (liquefying  gelatin); 
(^)  diastatic,  transforming  starches  into  sugars;  (^)  inverting,  changing 
nonfermentable  sugars  into  fermentable;  (^d^  emulsifying;  (^)  coagu- 
lating; (_/■)  liquefying;  (^)  hydrolytic,  converting  urea  into  ammonium 
carbonate;  (/;)  fat-splitting;  (/)  oxidizing;  and  (y)  nitrifying. 

4.  Ptomains. — Many  bacteria  are  known  to  produce  poisonous  crys- 
talline substances  known  as  ptomains,  or  putrefactive  alkaloids.  These 
bodies  are  a  product  of  the  action  of  bacteria  upon  dead  organic  mat- 
ter, and  although  many  of  them  are  poisonous,  they  are  to  be  distin- 
guished from  the  toxins  upon  which  the  manifestations  of  most  of  the 
infectious  diseases  depend.  The  poisoning  caused  by  eating  decomposed 
meat,  fish,  cheese,  or  decayed  vegetables,  for  example,  is  due  to  the  pres- 
ence of  ptomains  in  the  food  eaten.  Quite  a  large  number  of  ptomains 
have  been  isolated  and  their  chemical  compositions  have  been  determined 
with  accuracy,  especially  by  Vaughan  and  Novy.  Some  of  them  are 
harmless,  others  are  extremely  poisonous. 

5.  Proteins. — Buchner  isolated  poisonous  substances  which  he  called 
proteins.  Koch's  old  tuberculin  belongs  to  this  class  of  bacterial  prod- 
ucts. A  protein  is  a  substance  free  from  sulphur  which  is  obtained 
by  the  action  of  potassium  hydroxid  upon  a  proteid  (an  albuminous 
constituent  of  an  organism).  Buchner  found  these  substances  were  not 
affected  by  heat,  but  capable  of  producing  fever  and  inflammation. 

6.  Toxins  and  Toxalbumins. — The  term  toxin  is  now  generally  used 
to  designate  the  albuminoid  products  of  bacteria,  although  there  is 
chemically  a  difference  between  toxins  and  toxalbumins.  A  toxalbumin 
is  an  albuminoid  body  precipitated  from  bouillon  cultures  of  the  bac- 
teria by  the  agents  which  ordinarily  precipitate  albumin.  They  are 
similar,  both  in  origin  and  in  toxicity,  to  ricin,  the  toxalbumin  of  the 
castor  bean,  and  abrin,  that  of  the  jequirity  bean.  Some  authors  com- 
pare them  also  to  the  venom  of  snakes  or  to  the  enzymes ;  while  others 
classify  them  with  the  albumoses  or  peptons.  Toxin  is  regarded  by 
some  investigators — among  them,  Roux  and  Yersin — as  a  ferment  of  the 
same  group  as  the  diastatic  and  hydrolytic,  and  the  toxalbumin  is 
looked  upon  by  them  as  simply  an  impure  form  of  the  toxin  resulting 
from  its  combination  with  various  albuminous  substances  in  the  culture 
medium.  Brieger  and  Cohn  have  succeeded  in  obtaining  toxins  free  from 
albumin  reaction.  Uschinsky  claims  to  have  obtained  the  albuminoid 
poisons  of  tetanus  and  diphtheria  in  culture  media  free  from  albumin, 
and  more  recently  Brieger  and  Cohn  have  found  that  the  cholera  vibrio 
produces  a  nonalbuminous  toxin  in  Uschinsky's  culture  media.  At  pres- 
ent the  diphtheria  toxin  is  regarded  as  non-albuminous. 

It  is  believed  that  each  species  of  micro-organism  produces  a  toxin 
peculiar  to  itself,  hence  different  in  virulence,  as  in  other  attributes,  from 
those  produced  by  other  bacteria.     Outside  of  the  body,   the  virulence 


36  PRACTICE  OF  MEDICINE 

of  any  species  may  be  increased  or  diminished  in  many  ways,  as  by  vari- 
ations of  temperature  and  culture  media,  which  are  not  of  interest  here, 
except  in  so  far  as  they  suggest  that  similar  changes  may  occur  under 
other  conditions  of  growth.  Among  the  most  virulent  toxins  are  those 
of  tetanus,  of  which  0.00005  milligram  is  capable  of  killing  a  mouse 
weighing  15  grams,  and  that  of  diphtheria,  whose  highest  virulence 
is  almost  as  great. 

The  toxins  are  believed  to  enter  directly  into  chemical  union  with 
the  body-cells.  They  do  not  merely  enter  the  cells  in  the  form  of  a  solu- 
tion, as  is  the  case  with  mineral  poisons,  neither  do  they  destroy  the 
cell,  as  do  some  of  the  latter. 

Many  bacteria  are  capable  of  producing  more  than  one  toxic  agent; 
some,  in  fact,  produce  a  whole  series  of  toxins.  The  diphtheria  bacillus, 
for  example,  produces  not  only  the  diphtheria  toxin,  but  a  second,  which 
is  known  as  a  toxon.  Charrin  has  found  that  the  bacillus  pyocy.aneus 
produces  two  classes  of  products,  one  soluble  in  alcohol,  and  affecting 
the  nervous  system ;  the  other  insoluble,  slower  in  action,  and  producing 
varied  and  severe  phenomena  and  immunity.  The  tetanus  bacillus  pro- 
duces, in  addition  to  tetanospasmin,  another,  which  is  known  as  teta- 
nolysin;  and  the  cholera  spirillum  produces  penta-  and  tri-methyl 
endyamin,  methylguanidin,  and  other  toxins.  The  great  diversity  of  the 
manifestations  sometimes  seen  in  disease  may  be  accounted  for  in  part 
by  variations  in  the  proportions  of  these  toxic  substances. 

7.  Other  Products. — Many  bacteria  produce  other  chemical  substances 
through  their  action  upon  various  bodies.  In  the  presence  of  nascent 
hydrogen,  hydrogen  sulphid  is  formed  from  albuminous  matter,  powdered 
sulphur,  thiosulphates  and  sulphites.  In  the  same  manner,  blue  litmus, 
methylene  blue,  and  indigo  are  decolorized,  and  nitrates  are  converted 
into  nitrites  and  ammonia.  Aromatic  substances  are  formed  by  another 
class  of  bacteria.  The  most  familiar  of  these  are  indol,  skatol,  phenol, 
and  tyrosin.  Under  suitable  conditions,  fats  are  converted  into  fatty 
acids,  and  these  fatty  acids  may,  with  their  salts,  be  again  converted 
into  other  fatty  acids.  Putrefaction,  as  we  have  seen,  is  due  to  the 
action  of  bacteria  and  is  usually,  although  not  always,  attended  with 
the  production  of  malodorous  gases. 

For  the  other  chemical  phenomena  of  bacterial  activity,  the  student 
is  referred  to  works  on  bacteriology. 

THE  PATHOGENIC  BACTERIA, 

The  micro-organisms  which  are  capable  of  producing  disease  are  desig- 
nated pathogenic,  in  order  to  distinguish  them  from  the  larger  class, 
which  are  harmless  or  nonpathogenic.  The  former  class  is  constantly 
growing,  as  one  after  another  of  the  bacteria  supposed  to  be  innocuous  is 
found,  under  favorable  conditions,  to  cause  infection.  But  the  specific 
relations  of  bacteria  to  many  of  the  infectious  diseases  remain  unknown. 

Diseases  not  infrequently  pursue  an  unusual  course  on  account  of 
the  development  of  a  mixed  infection  by  the  entrance  and  growth  of 
more  than  one  kind  of  bacteria  at  the  same  time. 

Contagion. — An  infected  person  may  always  become  directly  or   in 
directly  a  source  of  infection  to  others.    Of  such  diseases  as  measles, 


INFECTION  37 

scarlet  fever,  and  smallpox  we  know  that  the  infectious  agent  may  be 
transmitted  through  close  contact,  and  we  say  that  these  diseases  are 
contagious.  There  are,  nevertheless,  other  means  of  transmission  which 
are  less  subject  to  demonstration.  We  assume  that  the  micro-organisms 
can  be  carried  through  the  air  to  a  greater  or  less  distance.  Welch 
has  shown,  however,  that  the  importance  of  the  air  as  a  carrier  of 
infection  has  probably  been  overestimated.  It  is  only  when  the  bacteria 
have  been  reduced  to  the  form  of  dry  dust,  or  when  they  adhere  to 
such  small  particles,  that  they  can  be  transferred  by  atmospheric  cur- 
rents. And  this  possibility  can  be  assumed  only  of  those  bacteria  that 
are  capable  of  retaining  their  vitality  against  ordinary  drying. 

The  importance  of  flies  and  other  insects  as  carriers  of  germs,  although 
suspected  for  a  great  many  years,  was  not  demonstrated  until  quite 
recently,  and  it  is  a  remarkable  fact  that  malaria,  the  disease  which 
has  been  regarded  as  the  type  of  air-borne  disease,  is  now  known  to  be 
transmitted  nearly  or  quite  exclusively  by  the  mosquito.  The  possibil- 
ities of  the  transmission  of  contagion  are  so  nearly  unlimited,  especially 
in  view  of  the  remarkable  tenacity  of  life  displayed  by  many  micro- 
organisms, that  we  should  not  be  too  ready  to  limit  the  number  of 
affections  in  which  such  transmission  is  possible.  It  is  remarkable  also 
to  what  extent  the  most  virulent  bacteria  can  be  handled  with  impunity 
in  the  laboratory  so  long  as  actual  contact  is  avoided. 

Susceptibility. — Each  infection  owes  its  origin  and  most  of  its  features 
to  the  action  of  a  definite,  specific  micro-organism,  but  it  does  not  follow 
that  the  entrance  of  a  specific  germ  will  under  all  circumstances  produce 
precisely  the  same  result.  The  variation  in  the  effect  is  due  in  part  to 
different  degrees  of  virulence  in  the  organism,  but  in  great  measure  to 
difference  in  the  susceptibility  of  different  individuals  or  in  the  same 
individual  at  different  times. 

All  the  predisposing  causes  of  disease  that  have  been  referred  to  may 
operate  to  render  an  individual  susceptible  to  infection,  but  the  most 
important,  perhaps,  are  age,  race,  previous  illness,  or  injury  and  fatigue. 
Some  diseases  are  peculiar  to  childhood,  others  to  adult  life.  Some  races 
are  immune  to  certain  infections;  the  negro  is  much  less  susceptible 
to  malaria  and  yellow  fever  than  is  the  white  man.  Some  diseases, 
notably  erysipelas,  rheumatism,  and  influenza,  render  a  person  more 
liable  to  reinfection  of  the  same  character,  and  others  increase  suscepti- 
bility to  infection  by  other  organisms.  The  influence  of  heredity  has 
no  doubt  been  exaggerated,  but  it  is  still  believed  that  a  tendency  to 
such  diseases  as  tuberculosis,  gout,  and  some  nervous  affections  can  be 
transmitted.  It  is  more  difficult  to  explain  the  greater  prevalence  of 
certain  diseases  at  one  season  of  the  year  than  at  others,  except  as 
the  conditions  favor  the  growth  of  bacteria.  Almquist,  who  has  made 
a  study  of  the  subject,  concludes  that  the  outdoor  temperature,  the 
moisture  of  the  air,  the  quality  of  the  dwellings,  and  the  mode  of  life 
all  have  a  bearing  upon  it. 

INFECTION. 

Definition. — Infection  is  the  condition  produced  in  the  body  by  the 
entrance  and  propagation  of  pathogenic  bacteria. 


SS  PRACTICE  OF  MEDICINE 

In  order  to  produce  disease  a  micro-organism  must  be  capable,  not 
only  of  gaining  entrance  to  the  bod)^,  but  of  growing  and  multiplying 
in  it.  Although  the  virulence  of  different  bacteria  varies  within  wide 
range,  a  greater  or  less  growth  is  required  of  any  species  to  produce 
enough  toxic  matter  to  induce  the  manifestations  of  disease.  Other 
influences  must  also  be  taken  into  consideration  in  the  study  of  this 
subject.  Park  aptly  says,  in  his  work  on  bacteriology  :  "To  understand 
at  all  the  production  of  disease  through  bacteria  we  must  recognize 
that  both  the  body  invaded  and  the  bacteria  which  invade  are  living 
organisms.  They  are  in  bulk  wide  apart,  but  both  have  life.  Just  as 
there  are  different  races  and  species  of  animals,  there  are  different  races 
and  species  among  bacteria,  and  just  as  the  descendants  of  one  animal 
species  under  changing  conditions  gradually  become  diverse,  so  do  the 
descendants  of  one  bacterial  species.  Considering  these  facts,  we  can 
readily  understand  how  all  of  the  bacteria  do  not  grow  equally  well  in 
every  variety  of  animal,  nor  even  find  the  body  of  the  same  animal 
always  equally  suitable." 

Micro-organisms  do  not  normall}-  exist  within  the  tissues  of  the  bod}'. 
They  must  invariably  enter  from  without.  The  usual  avenue  of  entrance 
is  one  of  the  mucous  membranes,  especially  the  respiratory,  the  alimen- 
tary, or  the  genitourinary.  Infection  may  occur,  however,  through  the 
external  auditory  canal  or,  in  the  presence  of  a  lesion,  through  the  in- 
tegument of  any  part  of  the  body. 

The  body  is  protected  in  many  wa}'s  from  the  entrance  of  bacteria,  and 
it  is  capable,  under  ordinary  circumstances,  of  destroying  a  certain  num- 
ber of  those  that  gain  entrance.  It  is  protected:  (i)  By  the  epithelial 
covering  of  the  exposed  surfaces  and  by  the  presence  of  cilia  and  mucus 
on  these  surfaces;  (2)  by  the  power  of  the  gastric  juice  and  mucus  to 
destroy  bacteria;  and  (3)  by  the  presence  in  the  normal  fluids  of  the 
body  of  substances  antagonistic  to  the  bacteria  or  neutralizing  to  their 
chemical  products;  (4)  certain  cells  in  the  blood  and  tissues  have  the 
power  of  destro)ang  bacteria;  and  (5)  many  germs  are  filtered  out  by 
the  lymph-glands.  Manfredi  has  found  microbes  in  nearly  all  the  lymph- 
glands,  especially  in  the  subcutaneous,  bronchial,  and  mesenteric.  It 
is  therefore  apparent  that,  in  order  to  produce  infection,  a  greater  num- 
ber of  bacteria  must  gain  entrance  to  the  system  than  the  system  is 
able  to  destroy. 

It  is  believed  by  most  investigatoi  s  that  there  must  be  a  point  of 
impaired  integrit}'  or  of  reduced  vitality  (locus  minoris  resistentise)  in 
order  to  render  infection  possible;  but  this  is  disputed  by  others,  es- 
pecially with  reference  to  the  respiratory  passages  and  alimentary 
canal.  Even  if  a  break  of  continuit}-  or  an  impairment  of  vitality 
is  essential,  however,  this  ma}^  be  so  slight  as  to  escape  the  most 
careful  search  for  it,  since  the  scratch  of  a  pin,  a  puncture,  or  the 
bite  of  an  insect  is  quite  sufficient.  The  term  cryptogenic  infection 
has  been  applied  to  those  instances  in  which  the  point  of  entrance  cannot 
be  determined. 

The  production  of  infection  depends  more  upon  the  multiplication 
of  the  bacteria  within  the  body  than  upon  the  number  entering.  With 
most  species  the  multiplication  is  rapid,  but  onl}^  after  they  have  found 
a    suitable  medium    for    their    subsistence.    With    the  exception  of  the 


INFECTION  39 

anthrax  bacillus,  they  do  not,  as  a  rule,  propagate  while  being  con- 
veyed through  the  blood. 

The  pathogenic  bacteria  show  many  peculiarities  in  their  method  of 
attacking  the  bod}^  One  group  grows  only  upon  a  circumscribed  area.  The 
diphtheria  bacillus,  for  example,  grows  upon  the  mucous  membrane  of 
the  respiratory  passages,  but  not  in  the  blood  or  beneath  the  skin. 
The  cholera  vibrio  grows  upon  the  intestinal  mucous  membrane,  but 
not  in  the  blood  or  tissues,  and  the  tetanus  bacillus  develops  in  wounds 
of  the  subcutaneous  tissues,  but  not  upon  the  surface  of  the  skin.  An- 
other group  grows  most  readily  in  certain  tissues,  but  is  capable  under 
favorable  conditions  of  more  extensive  invasion.  The  typhoid  bacillus, 
for  example,  finds  its  most  suitable  soil  in  the  lymph-follicles  of  the 
intestine  and  in  the  mesenteric  glands,  but  invades  also  the  spleen,  the 
blood,  and  other  tissues.  Although  the  tubercle  bacillus  is  capable  of 
almost  unlimited  invasion  of  the  body,  it  generally  remains  for  a  long 
time  confined  to  a  single  region,  as  the  cervical  lymph-glands  or  the 
apex  of  one  lung;  and  the  pneumococcus,  although  developing  most 
readily  in  the  lung,  sometimes  invades  the  blood,  connective  tissues,  and 
serous  membranes.  Some  bacteria  invade  the  system  generally,  while 
others  produce  isolated  foci. 

The  local  lesions  produced  by  the  bacteria  depend,  on  the  one  hand, 
upon  the  character  and  individuality  of  the  bacteria,  and,  on  the  other 
hand,  upon  the  condition  of  the  tissues,  the  soil.  In  many  instances, 
as  in  the  intestinal  lesions  of  typhoid  fever,  all  the  several  processes  of 
degeneration,  inflammation,  necrosis,  and  regeneration  occur  in  succession. 
But  the  same  type  of  inflammation  or  degeneration  is  not  always  pro- 
duced by  the  same  organism  under  different  conditions.  The  degenera- 
tion of  cells  and  probably  also  the  inflammation  may  be  in  some  instan- 
ces the  direct  result  of  the  action  of  the  bacteria  upon  the  tissues, 
but  it  is  generally  due  to  a  direct  or  indirect  action  of  their  chemical 
products  and  the  withdrawal  of  nutrition.  Local  disturbances  are  some- 
times an  expression  of  disturbed  innervation  resulting  from  the  action 
of  the  toxins  upon  the  nervous  system. 

The  general  manifestations  of  disease  depend  for  the  most  part  upon 
the  action  of  the  toxins  upon  various  organs  and  tissues,  upon  the 
nervous  system,  perhaps,  more  than  upon  any  other.  Some  investigators 
regard  the  toxalbumins  more  important  in  this  connection  than  the 
toxins.  Their  action,  when  artificially  introduced  into  the  body,  is  slower 
than  that  of  the  toxins,  often  being  delayed  for  hours  or  even  days. 
The  individuality  of  the  different  infections,  the  peculiarities  of  their 
clinical  manifestations  and  course,  through  observation  of  which  we 
are  able  to  diff'erentiate  one  from  another,  are  due  chiefly  to  the  varying 
action  of  different  toxins.  All  under  favorable  conditions  produce  fever, 
but  in  other  respects  their  manifestations  are  very  different. 

ANTAGONISM  OF  INFECTION. 

The  presence  of  bacteria  or  of  their  toxins  in  the  body  arouses  an 
antagonism  on  the  part  of  the  system,  one  element  of  which  is  mani- 
fested in  the  development  of  antagonistic  bodies  called  antitoxins.  The 
result  is  the  production  of  a  chemical  .body,  often  in  many  times  greater 


40  PRACTICE  OF  MEDICINE 

quantity  than  is  actually  required '  for  the  neutralization  of  the^  toxin 
that  occasioned  its  formation.  With  regard  to  this  antagonistic  action 
of  the  body  there  are  many  theories,  no  one  of  which  fully  accounts  for 
all  the  phenomena.  The  more  important  of  them  may  be  grouped 
under  the  two  heads  of  cellular  activity  and  chemical  activity. 

Phagocytosis. — One  of  the  most  important  theories  of  cellular  action 
is  that  of  phagocytosis.  It  is  based  upon  the  behavior  of  certain  cells 
toward  inanimate  particles  of  matter,  first  observed  by  Virchow  in 
1840,  and  toward  living  bacteria  as  described  by  Koch,  Sternberg,  and 
Roser  from  1878  to  1881,  but  given  greater  importance  by  the  investi- 
gations of  Metchnikoff,  published  in  1884.  It  was  observed  that  these 
cells  had  the  power  of  seizing  or  swallowing,  and  dissolving  or  digesting, 
certain  bacteria.  The  cells  were  therefore  named  phagocytes.  Metchnikoff 
observed  further  that  there  are  two  kinds  of  cells  thus  engaged — one 
motile,  the  other  stationary.  The  former  class  consists  of  large  uninu- 
clear leucocytes  known  as  macrophages,  having  much  protoplasm  and  a 
prominent  nucleus,  sometimes  lobate  in  form  (the  polymorphonuclear 
macrophagocyte,  or  eosinophile  leucocyte  of  Ehrlich),  and  the  smaller 
microphagocyte,  having  either  several  nuclei  or  a  single  nucleus  in  the 
act  of  splitting.  The  stationary  or  fixed  phagocytes  are  regarded  as 
derivatives  of  connective  tissue,  endothelium,  and  other  tissues.  The 
motile  phagocytes,  through  their  ameboid  movements,  possess  not  only 
the  power  of  seizing  the  bacteria,  but  they  are  able  to  move  for  some 
distance  toward  their  prey  and,  having  seized  it,  to  carry  it  through  the 
circulation  to  a  place  of  deposit,  especially  to  the  spleen.  The  attraction 
apparently  exerted  by  a  microbe  for  the  leucocyte  has  been  called  chemo- 
taxis.  These  cells  have  also  a  power  of  selection  through  which  they 
seize  by  preference  bacteria  that  are  dead,  or,  if  more  than  one  species  is 
present,  that  which  will  prove  the  less  harmful  to  themselves.  Metchni- 
koff demonstrated,  however,  that  they  can  envelop  living  germs,  by 
successfully  cultivating  bacteria  which  he  had  found  thus  enveloped. 

Phagocytosis  is  almost  universally  present  in  the  infections ;  and  the 
more  immune  the  subject  of  the  disease,  the  greater  is  the  affinity  shown 
by  the  phagocytes  for  the  bacteria. 

Chemical  Theory. — This  theory  does  not  replace  that  of  phagocytosis, 
but  rather  throws  additional  light  upon  the  phenomena  of  infection  and 
immunity.  It  deals  on  the  one  hand  with  the  production  of  toxins,  and 
on  the  other  hand  with  the  cellular  activity  developed  as  a  result  of 
their  production.  As  has  been  previously  stated,  the  presence  of  micro- 
organisms or  of  their  toxins  in  the  blood  calls  forth  the  development, 
chiefly,  perhaps,  by  the  leucocytes,  of  antagonistic  anti-  bodies  to  which 
Buchner  gave  the  name  of  alexins.  These  are  chemical  in  character. 
They  have  either  a  bactericidal  action,  destroying  the  bacteria,  modi- 
fying their  vital  activity,  or  neutralizing  and  counteracting  the  toxins 
(cellulohumoral  theory). 

Ehrlich's  Theory. — Ehrlich  has  probably  offered  the  most  plausible 
theory  to  explain  the  affinity  that  exists  between  the  toxins  and  anti- 
toxins. The  theory  is  based  upon  the  supposed  stereochemical  con- 
figuration of  atomic  groupings.  Each  living  cell  is  assumed  to  possess, 
in  addition  to  its  nucleus,  numerous  side  chains  or  arms,  groups  of 
atoms  which  have  an  alltinity  for  some  assimilable  substance  and  act  as 


INFECTION  4r 

receptors.  The  normal  function  of  the  receptors  is  to  appropriate 
nourishment  to  the  cell.  They  combine  with  substances  introduced  as 
food.  It  is  assumed  that  the  food-stuffs  for  which  they  have  the  strong- 
est affinity  contain  groupings  similar  to  their  own.  In  like  manner  the 
toxin  molecule  is  regarded  as  having  at  least  two  sets  of  atomic  groups 
or  side  chains.  One  of  these  corresponds  to  the  food-stuffs  in  that  it  is 
able  to  unite  with  the  receptors  of  definite  cells.  It  is  therefore  desig- 
nated a  haptophore  group.  The  other  arm  of  the  toxin  contains  the 
poisonous  matter  and  is  designated  the  toxophore  group.  It  has  the 
power  of  injuring  or  destroying  protoplasm,  but  it  can  reach  it  only 
through  the  haptophore  groups  of  the  cells. 

It  is  then  assumed  that  when  a  toxin  enters  the  organism  or  is  pro- 
duced within  it,  the  haptophore  groups  of  the  molecules  immediately 
become  active  and  combine  with  the  receptors  of  cells  which  have  corre- 
sponding side  arms.  In  this  way  the  toxin  replaces  the  food-stuff  in 
the  cell,  and  one  of  the  first  results  is  an  interruption  of  nutrition.  The 
toxophore  group  is  slower  to  develop,  hence  a  period  of  incubation 
usually  intervenes  before  the  toxic  effects  of  an  infection  become  manifest. 
This  toxophore  group  is  also  less  stable  than  the  haptophore  and  may 
be  destroyed  by  heat  or  by  the  action  of  certain  chemical  agents,  thus 
converting  a  toxin  into  a  harmless  toxoid.  The  great  variation  in  the 
manifestations  which  arise  under  the  influence  of  different  infections  is 
in  a  measure  thus  explained,  for  all  cells  do  not  possess  groupings 
adapted  to  combine  with  all  toxins.  The  tetanospasmin  and  the  diph- 
theria toxin  find  their  strongest  affinity  in  the  cells  of  the  nervous 
system,  while  tetanolysin  combines  most  readily  with  the  receptors  of 
the  red  blood-corpuscle.  Other  toxins  find  suitable  receptors  in  the 
leucocytes  or  in  the  endothelium  of  the  blood-vessels. 

The  same  theory  has  been  applied  to  explain  the  formation  of  anti- 
toxins by  the  cells  of  the  body.  When  the  receptors  of  the  cells  which 
ordinarily  appropriate  food  have  combined  with  the  haptophores  of  a 
toxin,  the  function  of  the  cell  is  interfered  with,  a  process  of  regener- 
ation is  set  up,  and  new  receptors  are  formed.  Assuming  that  Weigei't's 
theory  of  regeneration  is  correct,  the  building  of  new  receptors  readily 
goes  beyond  the  needs  of  the  cell,  and  there  is  an  "  overcompensation." 
The  superabundance  of  receptors  results  in  their  being  thrown  off  into 
the  circulation,  and  these  detached  or  discarded  receptors  are  believed 
to  constitute  the  antitoxins.  Each  molecule  of  antitoxin  possesses  a 
side  chain  which  is  capable  of  uniting  with  a  molecule  of  toxin  and 
neutralizing'it. 

Under  the  names  bacteriolysins,  cytolysins,  hemolysins,  coagulins, 
agglutinins,  etc.,  a  great  many  substances  have  been  isolated  with  more 
or  less  precision  from  the  animal  juices  by  different  investigators.  They 
exist  in  part  normally,  and  are  in  part  formed  as  a  result  of  the  entrance 
of  infectious  organisms  or  their  toxins. 

With  reference  to  the  place  of  origin  of  the  numerous  anti-  bodies  a 
great  many  investigations  have  been  made.  The  results  seem  to  show 
that  what  are  not  produced  by  the  blood-cells,  chiefly  the  leucocytes, 
are  formed  in  those  organs  to  which  the  blood-cells  owe  their  origin, 
particularly  in  the  spleen,  lymphatic  glands,  and  bone  marrow.  Koudri- 
ascheff  has  expressed  the  belief  that  the  enlargement  of  the  spleen  in 


42  PRACTICE  OF  MEDICINE 

infection  is  a  result  of  the  increased  demand  upon  it  for  the  manufac- 
ture of  white  blood-corpuscles. 

IMMUNITY. 

Immunity  is  a  state  of  the  system  in  which  it  has  the  power  to  resist 
the  entrance  of  pathogenic  bacteria,  to  prevent  their  propagation  after 
entrance  has  been  secured,  or  to  overcome  the  results  of  their  vital 
activity.  The  term  is  a  relative  one.  Absolute  immunity  is  rare,  while 
instances  of  partial  or  temporary  immunity  are  comparatively  common. 

Immunity,  whether  absolute  or  partial,  may  be  inherited  (natural) 
or  acquired.  It  is  possible  that  every  individual  possesses  some  degree 
of  natural  immunity  against  almost  every  infection.  He  has  at  least 
the  power  of  preventing  to  some  extent  the  entrance  of  infection,  and 
it  is  a  well-established  fact  in  experimental  infection  that  a  certain  num- 
ber of  bacteria  are  destroyed  after  their  introduction  into  the  body. 
It  is  only  after  this  power  of  resistance  has  been  overcome  that  infection 
occurs. 

Natural  immunity  is  sometimes  a  racial  property,  or  it  may  be  pe- 
culiar only  to  the  individual.  Racial  immunity  is  seen  in  the  almost 
complete  resistance  of  the  negro  to  yellow  fever  and  malaria,  and  in  the 
freedom  of  the  Japanese  from  scarlatina.  Barlow  has  expressively  de- 
fined natural  immunity  as  "the  inheritance  of  acquired  characteristics." 

Individual  immunity  is  closely  allied  to  personal  idiosyncrasy  or  to 
that  unaccountable  quality  which  renders  some  persons  immune  to  the 
venom  of  snakes. 

Acquired  immunity  is  often  the  result  of  accident,  as  that  which  is 
sometimes  conferred  by  a  previous  attack  of  the  same  infection.  The 
first  attack  of  many  diseases  leaves  the  individual  immune  from  further 
attacks.  This  is  always  true  of  3/ellow  fever  and  generally  true  of  ty- 
phoid fever  and  the  exanthemata.  In  typhoid  fever,  however,  the  im- 
munity is  probably  not  developed  until  some  time  after  convalescence, 
for  a  full  relapse  sometimes  occurs  several  weeks  after  convalescence. 
Another  class  of  diseases  confers  immunity  from  a  slightl)^  different 
infection. 

Immunity  may  be  artificially  induced  («•)  by  the  introduction  of 
another  infection,  as  in  vaccination,  (^f)  by  the  injection  of  cultures 
of  a  specific  microbe  which  have  been  reduced  in  virulence  or  of  cultures 
from  which  the  living  organisms  have  been  removed  or  destroj^ed  by 
heat  or  other  means,  or  (<:)  by  the  injection  of  the  serum  of  animals 
that  have  been  rendered  immune.  Artificial  immunity  is  not  as  a  rule 
so  lasting  as  that  which  is  inherited  or  as  that  acquired  from  a  pre- 
vious attack  of  the  same  disease. 

The  mechanism  of  immunity  has  been  variously  explained.  It  is 
probable  that  the  process  is  not  the  same  in  all  instances  and  that 
no  single  theory  will  ever  account  for  its  man}^  features.  The  fact  often 
seems  to  be  overlooked  that  an  individual  may  be  immune  to  the  action 
of  a  microbe,  but  not  to  the  toxin  which  it  produces,  and  \ace  versa. 
Buchner,  as  already  stated,  attributes  it  to  the  presence  of  alexins  in 
the  body.  Another  explanation  attributes  the  inhibitory  influence  of  the 
serum  to  its  power  to  produce  a  change  in  the  vital  properties  of  the 


IMMUNITY  43 

bacteria,  but  this  has  been  shown  not  to  be  universally  true.  The  theory 
of  phagocytosis  attributes  immunity  to  the  power  of  the  cells  to  destroy 
the  bacteria.  This  has  been  somewhat  modified  in  the  cellulohumeral 
theory,  which  attributes  to  the  cells  the  power  of  producing  chemical 
substances  destructive  of  the  bacteria  or  capable  of  overcoming  or  coun- 
teracting their  action.  The  phagocyte  is  believed  not  only  to  envelop 
the  microbe,  but  to  produce  a  chemical  substance  for  its  destruction 
or  to  neutralize  the  toxin.  Metchnikofif  speaks  of  the  "complicated 
interplay  of  the  biological  and  chemical  functions  of  living  cells."  Man- 
fredi  has  shown  as  a  result  of  experiments  that  the  lymph-glands  act 
in  the  capacity  of  filters  for  the  removal  and  retention  of  bacteria, 
and  that  a  specific,  latent  microbism  is  developed  in  these  glands  by 
virtue  of  which  the  body  is  rendei-ed  immune  to  the  diseases.  In  other 
words,  the  existence  of  a  latent  infection  in  these  glands  so  afifects  the 
general  system  as  to  prevent  reinfection  by  the  entrance  of  organisms 
of  the  same  species.  F.  A.  Packard,  in  support  of  this  theory,  directs 
attention  to  the  fact  that  evidence  of  former  tuberculous  involvement 
of  the  superficial  lymphatic  glands  is  rarely  found  in  cases  of  pulmonary 
tuberculosis. 

The  early  theory  of  Chauveau,  that  the  cells  of  the  body  become 
accustomed  to  the  poison,  is  still  recognized  by  many  as  an  accessory 
feature  in  general  immunity. 

Ehrlich  has  applied  his  theory  of  chemical  afiinity  to  the  explanation 
of  both  natural  and  acquired  immunity.  In  natural  immunity  the  cells 
of  the  animal  organism  do  not  furnish  side  chains  capable  of  forming 
a  chemical  union  with  the  toxin.  Acquired  immunit}^  is  due  to  the  over- 
production of  receptors  by  the  cells  of  the  body.  Those  which  are  pro- 
duced in  excess  of  the  requirements  of  meeting  and  counteracting  the 
toxins  present  are  thrown  off  into  the  circulation  and  remain  ready 
to  combine  with  any  toxin  having  the  same  affinity  that  may  there- 
after be  formed  or  gain  entrance  to  the  body. 

As  a  result  of  the  studies  of  immunity,  artificial  antitoxins  have  been 
produced  with  more  or  less  success.  The  best  known  examples  of  these 
are  the  antitoxins  of  diphtheria,  tetanus,  bubonic  plague,  and  streptococ- 
cus infection. 

It  has  been  shown  further  that  the  antitoxin  may  disappear  from 
the  blood  without  necessary  loss  of  immunity,  and,  on  the  other  hand, 
that  death  ma}^  occur,  doubtless  as  a  result  of  extreme  susceptibility, 
while  the  blood  is  saturated  with  antitoxin.  It  should  be  borne  in  mind 
also  in  this  connection  that  an  antitoxin  is  merely  an  antagonistic  or 
neutralizing  agent,  and  in  no  sense  one  possessing  powers  of  regenera- 
tion. While  it  assists  the  body  to  resist  and  to  counteract  infection, 
it  does  not  directly  assist  in  the  processes  of  repair  that  are  necessary 
for  restoration  to  health. 


PART    II. 

PRACTICAL    MEDICINE. 


SECTION   I. 
The  Infectious  Diseases. 


TYPHOID  FEVER. 

ENTERIC  FEVER,  ABDOMINAL  TYPHUS,  EXANTHEMATIC  TYPHUS,  AUTUMNAL 

FEVER. 

Typhoid  fever  occurs  endemically  or  epidemically  in  all  parts  of  the  world.  No 
climate,  no  locaUty,  is  exempt  from  it,  but  in  some  regions  its  virulence  is  greater 
than  in  others.  In  the  United  States  it  prevails  with  greater  severity  along  the  Atlantic 
and  Gulf  coasts  and  on  the  shores  of  the  Great  Lakes.  In  Canada  and  on  the  Rocky 
Mountain  plateaux  it  usually  assumes  a  mild  form.  It  was  first  introduced  into  Puerto 
Rico  and  Hawaii  by  our  armies  in  1898.  The  name  Typhoid  is  derived  from  rvcpog, 
cloud  or  smoke,  and  refers  to  the  obscuring  of  the  mind  incident  to  the  disease. 

Definition. — An  infectious  disease  of  about  four  weeks'  duration, 
caused  by  the  bacillus  typhosus,  characterized  pathologically  by  lesions 
in  the  lymph-follicles  of  the  intestine,  the  mesenteric  glands,  spleen,  and 
other  organs,  and  clinically  by  a  continuous  fever,  usually  attended 
with  asthenia,  great  mental  depression,  diarrhea,  a  rose-colored  rash, 
and  a  tendency  to  intestinal  hemorrhage. 

Etiology. — The  specific  cause  of  the  disease  is  the  bacillus  of  Eberth. 
The  avenue  of  invasion  is  believed  to  be,  in  most  cases,  the  alimentary 
canal.  The  bacilli  enter  with  the  food  or  drink,  escape  the  destructive 
action  of  the  gastric  juice,  and  pass  through  the  intestine  until  they 
reach  the  lymph-follicles,  where  they  find  conditions  suitable  for  their 
propagation.  From  the  follicles  they  enter  the  lymph-vessels  and  thence 
pass  into  the  blood,  to  be  disseminated  throughout  the  system.  Their 
poison,  typhotoxin,  is  regarded  as  an  ingredient  rather  than  a  product 
of  the  bacilli,  since  filtered  cultures  are  almost  free  from  it. 

^^^.— Youth  and  early  adult  life  are  the  periods  of  greatest  suscepti- 
bility. More  than  half  the  cases  occur  between  the  fifteenth  and  thirtieth 
years.  The  disease  may  be  encountered,  however,  from  early  infancy  to 
extreme  old  age.  It  may  be  congenital  when  the  mother  becomes  in- 
fected during  the  last  months  of  pregnancy  and  communicates  it  to 
the  fetus.  The  intestinal  lesions  have  been  found  in  premature  infants 
and  in  those  dying  in  the  first  weeks  of  life.  A  few  cases  have  been 
reported  in  persons  over  80  years  old.  The  greatest  mortality  has  been 
between  20  and  30. 

&;c. —Hospital  records,  as  a  rule,  include  a  much  greater  number  of 
men  than  women,  but  under  equal  exposure  the  sexes  are  about  equally 
attacked.  Pregnancy  and  lactation  are  thought  to  afford  partial  pro- 
tection to  women. 


48  PRACTICE  OF  MEDICINE 

Susceptibility. — Some  persons  and  some  families  appear  to  be  less 
susceptible  than  others,  but  absolute  immunity  is  at  least  rare.  The 
disease  affects  almost  equally  people  in  all  walks  of  life.  If  robust 
working-men  are  oftener  attacked,  as  has  been  suggested,  it  is  prob- 
ably on  account  of  greater  exposure  and  less  regard  of  prophylaxis. 
Early  settlers  and  the  armies  of  invasion  are  especially  prone  to  the 
infection,  but  this  is  doubtless  due  to  the  greater  liability  of  their 
uncertain  water  supply  to  contamination.  One  attack  generally  pro- 
tects from  future  infection.  Such  chronic  affections  as  phthisis  and  heart 
disease  are  believed  by  some  authors  to  partially  protect.  Bad  ventila- 
tion, overcrowding,  intemperance,  and  mental  and  physical  fatigue  pre- 
dispose, if  at  all,  by  increasing  susceptibility.  Gross  errors  in  diet,  and 
filth,  favor  infection.  Intestinal  catarrh  involving  desquamation  of 
epithelium  is  regarded  by  some  authors  as  essential  to  infection  by 
establishing  a  nidus  for  the  growth  of  the  bacilli,  but  others  regard 
this  as  of  little  importa.nce. 

Season. — Autumn  is  the  season  of  its  greatest  prevalence,  hence  the 
name  autumnal  fever;  but  in  many  localities,  especially  in  the  great 
cities,  it  occurs  in  sporadic  form  the  year  round.  That  it  is  most  prev- 
alent after  a  hot,  dry  summer,  a  belief  that  has  been  handed  down  for 
many  years,  is  not  confirmed  by  all  authorities.  Drought  probably  has 
its  influence  in  favoring  the  concentration  of  the  infectious  agent  in:the 
depleted  streams  and  springs  and  in  favoring  the  draining  of  contam- 
inated foci. 

Waier  and  Food  Coniamination. — Typhoid  fever  is  typically  a  water- 
borne  disease.  Many  of  the  most  notable  epidemics  have  arisen  from 
the  pollution  of  the  water-supply  of  a  town  with  the  dejections  of  a 
single  case,  and  it  is  in  most  instances  owing  to  similar  contamination 
of  the  drinking-water  that  it  is  so  prevalent  in  armies  and  new  settle- 
ments. The  disease  is  carried  with  the  invaders,  and  the  contagium 
reaches  the  water-supply  through  careless  disposal  of  the  stools  from 
the  infected  persons  of  the  party.  A  notable  illustration  usually  referred 
to  was  the  epidemic  of  Maidstone,  England,  in  1S97.  Over  1,900  cases 
occurred  among  35,000  inhabitants,  and  in  over  95  per  cent  of  the 
cases  the  infection  was  traced  to  a  definite  contamination  of  the  water- 
supply.  Defective  drainage  is  ordinarily  the  most  prolific  source  of 
water  contamination,  but  the  germs  are  probably  never  carried  in  the 
vapor  arising  from  sewers,  however  contaminated  it  may  be  in  other 
respects.  The  bacilli  have  been  carried  in  ice.  Milk  becomes  a  source 
of  infection  through  the  addition  of  polluted  water,  or  by  the  use  of 
such  water  to  cleanse  the  vessels  in  which  it  is  stored.  Shellfish,  espe- 
cially oysters,  have  in  several  instances  been  the  source  of  widespread 
infection,  and  the  bacilli  have  been  repeatedly  found  in  them. 

Contagion.— Tht  danger  of  contagion  by  direct  contact  is  very  slight, 
except  to  the  nurse  and  the  laundress  who  wait  upon  the  patient  and 
wash  his  linen.  Germs  are  probably  seldom  or  never  conveyed  by  the 
air,  although  they  resist  ordinary  drying.  It  is  evident  that  the  hands 
of  the  nurse,  the  thermometer,  and  utensils  used  by  the  patient  if  by 
any  possible  means  contaminated  with  the  feces  or  urine,  may  convey 
the  bacilli,  unless  thoroughly  sterilized;  and  it  has  been  sufficiently 
demonstrated  that  flies  may  serve  as  carriers  of  the  virus. 


TYPHOID    FEVER  49 

Bacteriology. — The  bacillus  is  usually  a  rather  short  rod,  measuring 
about  2.5,'/  in  length,  or  one-third  the  diameter  of  the  red  blood-cor- 
puscle, and  about  a  third  as  wide  as  it  is  long.  It  is  sometimes  longer 
and  more  slender,  and  frequently  forms  chains  of  considerable  length. 
It  resists  freezing  and  a  temperature  of  156°  F.  (69.0^  C),  but  is  killed 
by  complete  drying,  exposure  to  bright  sunlight  for  two  hours,  or  to 
the  air  for  a  longer  period.  In  form  it  is  not  unlike  the  colon  bacillus, 
but  it  is  actively  motile,  having  long  flagella.  It  is  not  known  to  form 
spores,  but  sometimes  shows  granules  at  the  poles.  Its  growth  within 
the  body  is  remarkably  rapid.  Great  numbers  of  bacilli  are  found  be- 
tween the  cells  of  the  lymph-follicles  in  the  intestine  and  in  smaller  foci 
within  the  mesenteric  lymphatic  glands,  in  the  spleen,  liver,  kidneys, 
pleurae,  and  meninges.  They  are  found  also  in  blood  drawn  from  the 
rose-spots  of  the  skin,  and  in  a  few  instances  have  been  obtained  in  that 
drawn  from  the  general  circulation;  sometimes  in  the  bone  marrow  and 
other  tissues.  Bacilli  have  even  been  found  in  the  bile,  sweat,  sputum, 
and  tears ;  in  the  milk  of  pregnant  women,  and  for  months  after  recov- 
ery in  abscesses  and  diseased  joints.  The  stools,  and  in  some  cases  the 
urine,  contain  large  numbers  of  them  after  the  tenth  or  twelfth  day  of 
the  disease.  They  disappear  from  the  stools,  as  a  rule,  about  two  weeks 
after  the  fever  ceases,  but  they  have  been  found  in  the  urine  several 
months  later.  From  the  frequent  discovery  of  the  typhoid  bacillus 
alone  in  foci  of  suppuration,  Golgi  and  others  attribute  pyogenic  prop- 
erties to  them. 

Many  unsuccessful  attempts  have  been  made  to  produce  the  disease  by 
artificial  inoculation ;  but  most  of  the  lower  animals  have  proved  to  be 
resistant.  The  symptoms  produced  by  injection  of  bacilli  into  their 
blood  or  their  peritoneal  cavities  are  attributed  to  the  toxin  accompany- 
ing the  injection.    The  bacilli  are  generally  quickly  destroyed. 

The  bacilli  probably  do  not  have  a  permanent  independent  existence 
outside  of  the  human  body,  but  they  are  capable  of  retaining  vitality 
for  weeks  and  months  in  the  outer  world,  under  favorable  conditions, 
especially  in  moist  earth  and  in  water.  It  has  been  demonstrated  that 
they  can  resist  repeated  freezing  and  thawing  and  retain  life  for  25  days 
in  fresh  water  or  in  sterile  sea-water,  and  for  a  much  longer  time  in 
unsterilized  fecal  matter.  A  few  authorities,  led  by  Pettenkofer,  regard 
the  ground-soil  as  the  normal  place  of  development,  but  the  vast 
majority  of  investigators  maintain  that  the  original  source  of  infection 
is  always  a  previous  case  of  the  disease. 

Types  of  Infeciion.—Chiaxi  and  Kraus,  Hodenpyl,  Flexner,  and  others, 
by  a  series  of  investigations,  have  been  led  to  the  belief  that 
the  disease  may  be  divided  into  four  groups  corresponding  to  as  many 
forms  of  infection.  These  are  :  (i)  Ordinary  typhoid  fever  with  marked 
intestinal  lesions,  a  group  to  which  a  great  majority  of  the  cases  belong. 
(2)  Typhoid  septicemia,  a  general  infection  without  special  local  mani- 
festations. (3)  Typhoid  fever  with  lesions  elsewhere  than  in  the  intes- 
tine, a  form  in  which  the  disease  is  characterized  by  typical  clinical 
manifestations,  and  the  diagnosis  may  generally  be  confirmed  by  the 
demonstration  of  the  bacilli  in  the  blood  or  other  fluids  of  the  body 
and  by  the  Widal  test.  The  intestinal  lesions  are  very  slight  or  entirely 
absent,  the  principal  pathological  changes  being  found  in    the    lungs. 


50  PRACTICE  OF  MEDICINE 

spleen,  kidneys,  or  the  cerebrospinal  meninges.  (4)  Mixed  infections. 
This  term  is  restricted  in  its  application  to  cases  of  secondary  infection 
of  the  typhoid  patient  with  such  organ-isms  as  the  colon  bacillus,  the 
streptococcus,  staphylococcus,  or  pneumococcus.  Cases  of  double  infection, 
as  with  the  organisms  of  tuberculosis,  diphtheria,  or  malaria,  are  to  be 
excluded  from  the  group,  since,  in  such  cases,  two  diseases  coexist. 

Morbid  Anatomy. — The  specific  lesions  of  typhoid  fever  are  found 
in  the  lymphatic  system,  especially  in  the  solitary  and  agminated  folli- 
cles of  the  intestine,  the  mesenteric  glands,  and  the  spleen. 

T/ie  Litestines. — The  changes  may  involve  the  follicles  in  any  part 
from  the  jejunum  to  the  lower  end  of  the  ileum,  or  in  the  cecum  and 
colon,  but  they  are  generally  confined  to  the  lower  part  of  the  ileum. 
They  may  be  divided  into  four  kinds,  which  in  a  measure  correspond  in 
the  time  of  their  occurrence  to  the  clinical  division  into  four  weeks.  It 
should  be  borne  in  mind,  however,  that  the  weeks  represent  somewhat 
indefinite  periods  of  time,  often  slightly  more  or  less  than  seven  days. 
The  first  week  is  characterized  in  the  follicles  by  congestion  and  prolif- 
eration, the  second  by  degeneration  and  necrosis,  the  third  by  ulceration, 
and  the  fourth  by  cicatrization. 

1.  The  congestion  consists  in  an  accumulation  of  multinuclear  leuco- 
cytes, blood-plasma,  and  occasionally  some  red  blood-cells.  The  pro- 
liferation occurs  chiefly  in  the  endothelium  of  the  follicles  and  small 
lymph  channels.  The  young  cells  are  abnormally  large  and  speedily 
undergo  degeneration.  The  entire  follicle  becomes  swollen  and  unduly 
prominent.  Any  part  or  all  of  the  agminated  follicles  may  be  involved. 
The  infiltration  may  involve  also  the  submucosa  and  muscular  coat. 

2.  The  processes  of  degeneration  are  induced  by  the  irritant  action 
of  the  bacilli,  present  in  large  numbers,  and  are  favored  by  anemia  due 
to  occlusion  of  blood-vessels  by  pressure  or  thrombosis.  A  slough  is 
formed,  which  may  be  so  superficial  as  to  scarcely  destroy  the  epithelium 
or  so  deep  as  to  include  the  muscular  layer. 

3.  The  ulceration  corresponds  in  location  and  extent  to  the  follicular 
degeneration,  but  sometimes  attains  great  size  by  the  coalescence  of  the 
process  in  two  or  more  Peyer's  patches.  It  does  not  ordinarily  pene- 
trate deeper  than  to  the  submucosa,  but  it  may  extend  through  to  the 
peritoneal  covering  and  lead  to  perforation  of  the  bowel  under  the  force 
of  gaseous  distention.  The  edges  of  the  ulcer  aregenerally  much  elevated, 
soft,  and  overhanging;   the  floor  is  usually  smooth. 

4.  Cicatrization  is  accomplished  by  the  formation  of  new  fibrous 
connective  tissue. 

The  spleen  is  much  enlarged  and  engorged  with  blood;  it  is  at  first 
firm,  but  later  soft,  almost  diffluent.  It  contains  clumps  of  bacilli,  and 
not  infrequently  infarctions.     Spontaneous  rupture  has  rarely  occurred. 

Other  Organs. — Catarrhal  enteritis  of  variable  extent  is  usually  pres- 
ent, the  liver  is  generally  enlarged,  the  cells  granular  from  degenerative 
changes  and  crowded  with  fat.  It  frequently  contains  clusters  of  bacilli 
and  lymphoid  and  necrotic  nodules  which  are  sometimes  converted  into 
abscesses.  Acute  yellow  atrophy  has  been  noted.  The  mucous  mem- 
brane of  the  gall-bladder  is  so  uniformly  affected  as  to  virtually  con- 
stitute a  culture  soil  for  the  bacillus.  The  epithelium  of  the  renal  tubules 
shows  cloudy  swelling,  and  there  are  generally  clumps  of  bacilli  or  of 


TYPHOID  FEVER  51- 

round-cell  infiltration  which  sometimes  break  down  and  form  miliary 
abscesses.  The  latter  lesions  were  described  by  E.  Wagner  as  lymphom- 
atous  formations.  Acute  nephritis  rarely  occurs.  Pyelitis  and  cystitis 
are  occasionally  found.  The  pancreas  sometimes  shows  proliferation  of 
cells,  with  cloudy  swelling  and  fatty  degeneration.  Bacilli  have  been 
found  in  it.  Hypostatic  congestion  and  edema  of  the  lungs,  pharyngitis  and 
larj'ngitis,  sometimes  of  an  ulcerative  form,  may  be  found.  Myocarditis 
occasionally  develops,  less  frequently  pericarditis  or  endocarditis.  In 
the  latter  condition,  bacilli  are  found  in  the  valvular  vegetations.  Peri- 
tonitis seldom  occurs  in  the  absence  of  perforation.  It  very  rarely 
proves  to  be  a  conservative  process,  causing  closure  of  the  opening 
without  more  extensive  involvement  of  the  peritoneum.  Parenchyma- 
tous degeneration  of  the  muscles,  thrombosis  of  the  femoral  veins,  men- 
ingitis, and  peripheral  neuritis  are  sometimes  met  with.  Among  the 
less  frequent  lesions  are  suppurative  parotitis,  otitis,  infarction  or 
gangrene  of  the  lungs,  edema  of  the  glottis,  and  gastric  or  esophageal 
ulceration. 

The  Blood. — The  bacilli  have  been  repeatedly  discovered  in  the  blood, 
reaching  it  from  the  lymph-vessels  of  the  mesentery,  in  all  probability 
through  the  thoracic  duct,  where  they  have  been  found  in  much  greater 
numbers  than  in  the  blood.  Pyogenic  organisms  may  also  be  discovered. 
In  other  respects  the  blood-changes  correspond  to  those  of  secondary 
anemia ;  the  red  corpuscles  are  reduced  in  number  and  their  hemoglobin 
is  diminished  in  a  still  greater  proportion,  giving  the  disks  a  pale  ap- 
pearance. The  leucoc37tes  are  not  increased  until  convalescence  begins, 
except  in  rare,  complicated  cases.  The  absence  of  leucocytosis  is  a  dis- 
tinctive feature  of  the  disease.  The  osmotic  tension  of  the  blood  is 
remarkably  constant;  the  freezing-point  remaining  within  the  narrow 
limit  of — 0.55°  and  — 0.57°  C. 

Symptoms. — General  Course. — In  a  typical  case  the  period  of  incuba- 
tion is  generally  marked  by  a  feeling  of  lassitude,  a  disinclination  to 
work,  or  undue  fatigue  after  slight  exertion,  with  headache,  vertigo, 
possibly  a  slight  nose-bleed,  a  furred  tongue,  loss  of  appetite,  nausea, 
aching  pains  in  the  back  and  legs,  sometimes  colicky  pains  in  the  ab- 
domen. Chilly  sensations  are  usually  felt;  a  distinct  rigor  is  very  ex- 
ceptional. The  feeling  of  illness  is  more  pronounced  toward  evening 
and  increases  with  each  succeeding  day.  The  bowels  are  generally  con- 
stipated. The  incubation  lasts  from  7  to  14  days  as  a  rule,  but  may 
be  much  shorter  or  it  may  continue  as  long  as  2 1  days.  Some  cases 
arc  characterized  by  a  rather  severe  prodromal  stage  of  only  three 
or  four  days'  duration.  The  manifestations  of  illness  depend  largely 
upon  the  temperament  of  the  patient.  Some  persons  are  greatly  dis- 
tressed, while  others  only  realize  that  they  have  not  been  altogether 
well  for  two  or  three  weeks,  after  the  more  severe  symptoms  have  de- 
veloped. 

First  Week. — The  period  of  invasion,  or  first  week  of  the  disease,  begins 
with  the  elevation  of  temperature;  but  as  the  patient  frequently  does 
not  consult  a  physician  at  this  early  period,  the  exact  time  of  the  onset 
is  often  unknown.  It  that  case  the  beginning  of  the  disease  is  generally 
reckoned  from  the  day  on  which  the  patient  first  remained  in  bed.  The 
chilly  sensations  now  give  place  to  fcverishness;  the  weakness  increases, 


52  PRACTICE  OF  MEDICINE 

but  the  aching  pains  subside  after  a  few  days'  rest.  The  headache  be- 
comes more  severe  and  the  abdominal  pains  may  perhaps  continue. 
SHght  deafness  is  often  noticeable.  The  patient  becomes  nervous  and 
irritable.  His  sleep  is  restless  and  broken  by  dreams.  The  tempera- 
ture gradually  rises,  each  evening  showing  from  i''  to  1.5 '^  F.  greater 
elevation  than  the  preceding,  until  103"  or  104" -F.  (39.5'' — 40°  C.)  is 
reached.  The  pulse  is  rapid,  generally  from  100  to  110;  it  is  full,  but 
its  tension  is  low;  sometimes  it  becomes  dicrotic.  The  tongue  is  coated 
with  a  white  or  yellowish  fur,  except  at  the  tip,  which  may  be  unnaturally 
red.  It  is  often  tremulous.  The  papillae  may  be  prominent.  Nausea 
sometimes  continues,  vomiting  is  occasionally  troublesome,  and  there  is 
no  appetite.  The  lips  become  dry,  and  thirst  is  complained  of.  Sore- 
throat,  slight  pharyngitis  or  laryngitis,  and  bronchial  catarrh  are  not 
infrequent  accompaniments.  Nose-bleed  sometimes  first  makes  its  ap- 
pearance in  this  stage;  it  is  generally  slight,  only  a  (ew  drops  of  blood 
being  lost.  The  face  is  pale,  with  tinges  of  red  upon  the  cheeks;  the 
pupils  are  generally  dilated.  Diarrhea  may  develop  spontaneously,  but 
is  often  induced  even  by  an  unusually  mild  purgative.  In  some  cases, 
however,  diarrhea  is  absent  throughout  the  entire  course  of  the  disease, 
and  there  may  be  an  obstinate  constipation.  The  urine  is  diminished 
in  quantity,  high  in  color  and  specific  gravity;  the  urea  is  increased, 
chlorides  diminished,  and  traces  of  albumin  are  sometimes  found,  as  in 
other  febrile  diseases.  The  abdomen  generally  becomes  distended  and 
somewhat  tender,  especially  in  the  right  iliac  fossa.  Gurgling  is  fre- 
quently detected  by  palpation  in  this  region,  especially  if  diarrhea  be 
present.  Enlargement  of  the  spleen  usually  becomes  recognizable  by 
the  close  of  the  first  week. 

Second  Week. — The  symptoms  become  aggravated.  The  temperature 
continues  high  and  the  range  is  uniform  throughout  the  week,  with  but 
slight  morning  remission.  The  pulse,  still  rapid,  even  reaching  120,  is 
not  generally  dicrotic,  although  it  may  have  been  so  in  the  first  week; 
but  its  volume  is  diminished.  The  heart's  action  is  weak  and  the  first 
sound  indistinct.  The  headache  generally  subsides,  but  the  deafness 
becomes  more  marked  and  the  eyes  are  sensitive  to  light.  The  nervous 
restlessness  of  the  first  week  gives  place  to  sopor,  but  although  the 
patient  sleeps  much  of  the  time,  his  rest  is  not  refreshing.  He  lies  on 
his  back  with  his  eyes  half  open,  his  arms  at  his  sides,  a  picture  of 
extreme  weakness.  He  often  slips  down  toward  the  foot  of  the  bed. 
When  aroused,  he  is  apathetic,  utterly  indifferent  to  his  surroundings, 
and  rarely  expresses  a  desire.  Delirium  of  a  wandering  or  muttering 
character,  accompanied  with  muscular  twitchings,  often  supervenes, 
especially  at  night.  The  face  has  a  dull,  listless  expression  and  some- 
times a  dusky  hue;  the  cheeks  become  more  flushed,  but  the  pallor  and 
emaciation  are  more  pronounced.  The  lips  are  dry,  the  tongue  brown 
and  parched,  and  tremulous  when  protruded.  The  abdominal  dis- 
tention (meteorism)  increases  and  the  diarrhea  continues;  there  are 
usually  three  or  four  stools  a  day,  generally  of  a  yellowish  brown 
color  and  of  "pea-soup"  consistence.  Sometimes  they  are  lumpy 
and  of  a  pale  buff  color.  Rose-colored  spots  usually  appear  by  the 
eighth  day  of  the  disease,  first  on  the  abdomen  or  on  the  sides  of  the 
thorax  and  in  the  lumbar  region.    There  mav  be  only  three  or  four,  or 


TYPHOID  FEVER  53 

a  dozen,  round,  slightly  elevated,  bright  red  maculae  about  an  eighth 
of  an  inch  (3  mm.)  in  diameter.  At  first  they  disappear  on  pressure,  but 
immediately  return.  Successive  groups  appear  for  about  ten  days,  each 
group  remaining  for  two  or  three  days.  They  are  sometimes  so  numer- 
ous, however,  as  to  resemble  the  eruption  of  measles,  appearing  on  the 
arms  and  legs  as  well  as  on  the  trunk.  The  disease  may  terminate 
fatally  toward  the  end  of  the  week,  with  profound  nervous  manifestations 
or  as  a  result  of  hemorrhage  or  perforation. 

Third  Week. — In  the  very  mild  cases  the  temperature  begins  to  show 
greater  remissions  during  the  night,  but  in  most  cases  the  symptoms 
are  the  same  as  in  the  second  week  or  more  severe.  In  the  more 
aggravated  cases  the  temperature  remains  high,  the  pulse  is  still  rapid 
and  weak,  sometimes  running,  and  the  emaciation  becomes  profound. 
The  nervous  manifestations  are  also  prominent.  The  patient  is  more 
apathetic,  often  delirious  or  semicomatose,  especially  at  night.  During 
the  day  he  spends  much  of  his  time  in  muttering  and  picking  at  im- 
aginary objects  on  the  bed  or  in  the  air.  Subsultus  tendinum  (a  jerking 
of  the  tendons  of  the  wrist  and  fingers)  is  often  pronounced.  Owing 
to  the  extreme  weakness  and  emaciation,  or  to  dryness  of  the  nostrils, 
the  mouth  often  remains  open,  the  tongue  becomes  hard  and  fissured 
and  sordes  appear  on  the  teeth.  Bedsores  are  apt  to  form.  Diarrhea 
and  meteorism  may  make  their  appearance  during  the  third  week.  Re- 
tention of  urine  and  incontinence  of  feces  are  at  times  troublesome 
symptoms.  The  stools  may  be  tinged  with  blood,  or  profuse  hemorrhages 
may  occur.  The  hemorrhage  is  sometimes  first  announced  by  a  sudden 
gush  of  blood  from  the  rectum,  which  leaves  the  patient  in  a  state  of 
collapse,  pulseless,  and  bathed  in  cold,  clammy  sweat,  with  temperature 
normal  or  subnormal.  Albuminuria  frequently  appears  in  this  week  of 
the  disease,  or,  if  present  in  the  preceding  week,  it  becomes  more  abun- 
dant. By  this  time,  also,  hypostatic  congestion  of  the  lungs  or  even 
pneumonia  may  develop. 

Fourth  Week. — This  is  the  period  of  beginning  convalescence  in  most 
cases.  The  improvement  may  be  delayed,  however,  into  the  fifth  or 
even  the  sixth  week,  rarely  longer,  when  complications  arise.  From 
the  middle  to  the  end  of  the  week  the  temperature  generally  reaches 
the  normal  in  the  morning  and  does  not  exceed  loi*^  or  102°  F. 
(38.8°  C.)  in  the  evening,  and  by  the  end  of  the  week  the  evening  temper- 
ature is  generally  normal.  Slight  evening  elevations  sometimes  persist 
into  the  fifth  week.  The  pulse,  as  the  fever  subsides,  becomes  stronger  and 
there  is  general  evidence  of  improvement.  The  symptoms  all  begin  to 
abate;  the  abdominal  tension  disappears  and  the  diarrhea  ceases;  the 
tongue  becomes  moist  and  the  sordes  disappear  from  the  teeth;  the 
appetite  returns,  the  sleep  becomes  normal,  and  the  patient  awakes  re- 
freshed, with  a  clear  mind.  But  relapse  or  reinfection  may  occur  after  sev- 
eral days  or  a  week  of  normal  temperature  and  apparent  convalescence. 

Convalescence  usually  begins  in  the  fourth  week,  occasionally  earlier 
in  mild  cases.  It  may  be  delayed,  however,  until  the  fifth  or  sixth  week. 
The  chief  danger  in  the  latter  cases  lies  in  the  weakness  of  the  heart. 
This  is  a  period,  too,  in  which  complications  and  sequelae  are  most 
likely  to  arise.  The  patient  first  recognizes  his  weakness  after  the  fever 
has  subsided.     But  although  he  is  for  a  time  unable  to  raise  himself 


54  PRACTICE  OF  MEDICINE 

in  bed,  an  effort  which  is  fraught  with  danger  on  account  of  the  liability 
to  heart  failure  and  the  possibility  of  rupturing  a  degenerated  muscle, 
his  strength  soon  begins  to  return.  By  the  end  of  a  week  his  desire  to 
leave  the  bed  often  becomes  so  strong  as  to  require  a  careful  watch  to 
be  kept,  and  his  appetite  demands  a  supply  of  food  that  is  altogether 
unsafe.  A  relapse  is  often  brought  on  b}^  yielding  to  either  of  these 
inclinations.  Other  prominent  features  of  the  convalescent  period  are 
the  anemia,  which  persists  for  several  weeks ;  the  falling  of  the  hair,  which 
sometimes  amounts  to  alopecia;  and  in  some  cases  profuse  sweating, 
especially  during  sleep.  From  four  to  six  weeks,  sometimes  several 
months,  and  in  the  worst  cases  a  year  may  be  required  for  full  restora- 
tion of  strength.  The  mental  faculties  are  generally  early  restored,  but 
in  other  cases  weeks  or  months  elapse  before  the  patient  becomes  fully 
normal  in  this  respect. 

Special  Types. — No  other  disease  presents  so  great  diversity  of  clinical 
manifestations,  particularly  with  reference  to  severity. 

In  mild  cases,  the  general  features  are  the  same,  but  all  the  symptoms 
are  less  severe.  The  patient  is  frequently  so  little  indisposed  that  he 
yields  to  confinement  with  reluctance.  In  this,  however,  lies  the  great- 
est danger,  for  the  intestinal  lesions  and  the  danger  of  hemorrhage  or 
perforation  are  often  just  as  great  as  in  the  more  characteristic  cases. 
Under  supervision,  however,  these  cases  are  rarely  attended  with  hemor- 
rhage, delirium,  or  other  serious  symptoms. 

In  the  so-called  abortive  form,  the  onset  of  the  disease  may  be  unusually 
severe.  The  onset  is  sometimes  announced  by  a  chill  and  early  rise  of 
temperature  to  103°  F.  (39.5°  C.)  or  higher.  The  rose-spots  may  be 
found  as  early  as  the  second  to  the  fifth  day,  and  they  may  be  numer- 
ous. The  fever  pursues  a  uniform  course,  but  begins  to  decline  by 
the  end  of  the  first  week  or  beginning  of  the  second.  In  fact,  the  case 
has  the  appearance  of  having  passed  unrecognized  during  the  first  week. 
The  abortive  form  appears  to  occur  more  frequently  in  Europe  than 
in  this  country. 

The  Severe  or  Fulminant  Form. — The  disease  pursues  a  course  of  un- 
usual severity  from  the  beginning,  especially  in  those  cases  in  which 
the  manifestations  on  the  part  of  the  nervous  S3-stem  are  most  pro- 
nounced. The  headache  is  extreme;  delirium  may  develop  early,  and 
in  it  the  patient  may  for  da3'S  wander  about  the  streets.  In  some  cases 
the  predominance  of  such  S3^mptoms  as  headache,  photophobia,  and  re- 
traction of  the  head  leads  to  a  suspicion  of  cerebrospinal  meningitis, 
or  the  drowsiness  and  stupor,  especially  in  children,  suggest  a  basilar 
meningitis;  and  in  yet  another  class  of  cases  such  special  features  as 
neuralgia,  acute  bronchitis,  pleuritic  pain,  persistent  vomiting  and  diar- 
rhea, or  acute  nephritis  prevent  the  recognition  of  the  true  character 
of  the  disease. 

Ambulatory  Form. — Another  class  of  cases  belongs  to  the  ambulatory 
or  walking  type  of  the  disease.  The  patient  often  persists  in  his  usual 
occupation  day  after  day  until  he  is  suddenly  stricken  down,  it  may 
be  late  in  the  second  week,  with  dehrium,  a  temperature  of  104°  or 
105°  F.  (40 — 40.5°  C.)  hemorrhage,  or  the  pain  occasioned  by  per- 
foration. 

An  afebrile  tvpe  has  been   described,   but   cxtrcmel}-   few  crises  have 


TYPHOID  FEVER  55 

been  seen  in  this  country.  The  course  of  the  disease  is  the  same  as  in 
the  ordinary  form,  except  that  the  temperature  remains  normal.  The 
characteristic  lesions  have  been  found  after  death. 

Other  forms  of  the  disease  have  been  named  and  described,  but  the 
deviation  of  type  in  most  of  them  has  been  due  to  the  development  of 
complications. 

In  children  the  disease  generall}^  pursues  a  mild  course,  but  the  rise 
of  temperature  may  be  more  abrupt,  and  it  is  often  high  in  the 
beginning.  Epistaxis  seldom  occurs  and  diarrhea  is  often  absent.  An 
initial  bronchitis  sometimes  occurs.  The  nervous  manifestations,  espe- 
cially wakefulness  and  delirium,  may  be  severe.  The  rash  is  usually 
slight,  but  it  may  be  so  profuse  as  to  resemble  measles.  Hemorrhage 
and  perforation  rarely  occur,  but  their  possibility  should  not  be  dis- 
regarded. The  mortality  has  been  greatest  in  those  rare  cases  that 
occur  in  the  first  year  of  life. 

In  the  Aged. — After  the  fortieth  year  the  disease  generally  runs  a  mild 
course,  but  the  mortality  is  greatly  increased  by  the  common  occurrence 
of  complications  on  the  part  of  the  heart  and  lungs. 

In  Pregnant  Women. — The  disease  is  rare  in  pregnane}'.  It  usually 
occurs  during  the  first  half  of  the  period.  The  mortalit}^  is  but  little 
above  the  normal.  Abortion  or  premature  delivery  generally  occurs 
during  the  second  week. 

Special  Symptoms  and  Complicaiions. — The  Facial  Aspect. — In  the  be- 
ginning of  the  disease  the  cheeks  are  flushed  and  the  eyes  often  have 
an  increased  luster,  but  by  the  end  of  the  first  week  the  countenance 
loses  its  animation  and  the  eyes  become  expressionless.  In  the  height 
of  the  fever  the  expression  becomes  dull  and  heavy,  and  the  face  has 
sometimes  a  dusky  color.  The  flush  does  not  usually  disappear  until 
the  fever  has  subsided,  and  then  for  the  first  time  anemia  becomes  ap- 
parent.   The  emaciation  is  progressive  throughout  the  disease. 

Temperature. — The  t3^pical  temperature  curve  of  typhoid  fever  is  one 
in  which,  during  the  period  of  invasion,  or  first  week  of  the  disease, 
the  elevation  is  from  1°  to  1.8°  F,  (0.5 — 1.0°  C.)  higher  than  at  the 
same  time  on  the  day  previous,  until  an  evening  temperature  of  103° 
or  104°  F.  (39.5 — 40°  C.)  is  reached,  about  the  fifth  or  sixth  day. 
It  then  pursues  a  uniform  course  during  the  second  week  or  fastigium, 
the  fluctuation  from  morning  to  night  being  little  more  than  occurs  in 
health.  During  the  third  week  it  becomes  remittent;  there  is  often  a 
diff'erence  of  3°  F.  or  more  between  the  morning  and  evening  records, 
and  toward  the  end  of  the  week  the  evening  temperature  usually  be- 
comes normal;  that  of  the  morning  may  be  slightly  subnormal  for  a 
few  days.  But  a  perfectly  typical  chart  is  unusual.  It  is  modified  in 
many  ways;  as  a  result  of  rest,  treatment,  and  complications,  or  un- 
recognizable influences. 

The  height  of  the  temperature  at  the  end  of  the  first  week  is  gen- 
erally an  index  to  the  severity  of  the  attack,  but  it  may  prove  a  fal- 
lacious guide.  The  principal  variations  from  the  usual  range  are:  (i) 
An  abrupt  rise  at  the  beginning  of  the  first  week,  especially  in  children  and 
in  cases  beginning  with  a  chill  or  convulsion.  In  children  the  fever  often 
pursues  a  strictly  remittent  course.  (2)  In  a  mild  or  abortive  form 
L'-ic  tcmperatuix'  l)egins  to  decline  early   in   the   second   week,   and   often 


56 


PRACTICE  OF  MEDICINE 


by  a  lysis  which  is  unusually  rapid.  Very  rarely  a  crisis  occurs,  the 
temperature  reaching  the  normal  within  from  12  to  24  hours.  (3)  Hy- 
perpyrexia may  occur  in  which  the  temperature  reaches  106°  to  108° 


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F.  (41.1° — 42.2°  C.)  in  the  evenings.  Such  cases  are  usually  fatal. 
(4)  A  chill  sometimes  occurs  during  the  second  or  third  week,  and  the 
temperature  is  elevated  two  or  three  degrees  above  its  former  course, 


TYPHOID   FEVER  57 

especially  when  malarrial  infection  complicates  the  case.  (5)  Recrudes- 
cence sometimes  occurs;  the  temperature,  after  running  a  mild  course 
for  a  few  days,  if  not  from  the  beginning,  suddenly  becomes  elevated. 
This  may  occur  during  convalescence,  when  it  is  usually  a  result  of  errors 
in  diet,  constipation,  or  nervous  excitement.  (6)  Hemorrhage  of  the 
bowel  causes  a  sudden  drop  of  temperature  to  the  normal  or  below  it, 
although  the  blood  is  sometimes  retained  within  the  bowel  and  the 
hemorrhage  is  said  to  be  concealed.  Perforation  is  followed  by  a  similar 
decline.  (7)  Sometimes  the  fever  continues  at  its  former  range  or 
pursues  a  more  or  less  irregular  course  for  six  or  eight  weeks.  Such 
cases  arouse  suspicion  of  sepsis  or  tuberculosis,  unless  the  diagnosis 
has  been  confirmed  by  bacteriological  and  blood  tests.  (8)  Occasionally 
the  temperature  curve  is  reversed,  the  morning  record  being  higher  than 
the  evening. 

With  the  exception  of  hyperpyrexia  and  a  sudden  fall  of  temperature, 
these  deviations  do  not  necessarily  indicate  danger  in  the  absence  of 
other  grave  symptoms.  The  persistence  of  fever  after  all  symptoms  on 
the  part  of  the  alimentary  canal  have  disappeared  is  often  a  nervous 
manifestation.  The  fever  of  relapse  frequently  pursues  a  course  similar 
to  that  of  the  original  disease,  showing  a  gradual  rise,  a  few  days  of 
fluctuation,  and  a  decline.  It  is  usually  shorter  than  the  original 
pyrexia. 

Chills  occurring  during  the  course  of  the  disease  are  often  indicative 
of  a  complication,  notably  hemorrhage,  sepsis,  malaria,  pneumonia,  or 
thrombosis.  They  may  be  produced  also  by  the  administration  of  anti- 
pyre'„ics  or  by  constipation,  but  they  cannot  always  be  accounted  for. 

Circulatory  System. — The  Blood. — Typhoid  bacilli  can  be  found  in  the 
blood  by  cultivation  on  suitable  media.  At  the  end  of  the  disease  other 
pathogenic  germs  may  also  be  found  in  such  cultures.  The  coagula- 
bility of  the  blood  and  the  fibrin-formation  are  normal  until  the  ap- 
proach of  defervescence,  and  the  specific  gravity  varies  only  with  the 
hemoglobin.  During  the  first  two  weeks  of  the  disease,  the  blood  shows 
little  change  except  concentration,  with  apparent  increase  of  the  cellular 
elements,  due,  as  a  rule,  to  diarrhea.  In  the  third  week  the  red  cells 
begin  to  decrease,  and  reach  the  minimum  about  the  time  of  deferves- 
cence. They  seldom  sink  below  2,000,000.  The  hemoglobin  undergoes  a 
relatively  greater  diminution,  and  it  is  restored  more  slowly  after  re- 
covery. The  number  of  leucocytes  seldom  departs  from  the  normal 
(8,000  per  c.mm.),  except  in  the  beginning,  when  the  count  is  relatively 
higher  on  account  of  concentration.  The  larger  forms  predominate. 
A  slight  leucocytosis  may  develop,  however,  at  the  beginning  of 
convalescence.  Cabot  does  not  find  it  a  constant  condition  at  this 
time,  but  observes  that  leucocytosis  may  fail  of  development  through 
inability  of  the  system  to  react,  even  in  the  presence  of  pneumonia  or 
suppuration,  in  a  very  exhausted  patient.  The  polymorphonuclear  cells 
diminish  as  the  other  forms  increase,  often  falling  below  60  per  cent, 
toward  the  end  of  the  disease,  thus  contrasting  strongly  with  their 
behavior  in  other  infections.  They  begin  to  increase  again  in  from  three 
to  ten  days  after  defervescence,  and  become  normal  in  number  in  the 
sixth  or  seventh  week.  Eosinophiles  are  present  in  small  numbers. 
When   acute  inflammatory  processes  develop,  as   after  perforation,  leu- 


58  PRACTICE  OF  MEDICINE 

cocytosis  immediately  develops,  the  polymorphonuclear  forms  predom- 
inating. During  convalescence  the  coagulability  of  the  blood  is  some- 
times greatly  above  normal. 

The  pulse  is  increased  in  rapidity,  as  in  all  fevers,  but  not  usually  to 
so  great  a  degree.  In  the  first  week  it  is  generally  above  loo,  but  full 
and  of  low  tension,  often  dicrotic.  With  the  progress  of  the  disease,  it 
becomes  small,  feeble,  and  more  rapid,  sometimes  reaching  150.  It  is 
rendered  suddenly  rapid,  small,  or  even  imperceptible  by  hemorrhage 
or  perforation  and  by  cardiac  dilatation.  It  becomes  rapid  and  irregu- 
lar, during  convalescence,  upon  the  slightest  exertion  or  excitement. 
Bradycardia  (slow  heart)  sometimes  occurs,  especially  during  conval- 
escence, and  inay  persist  for  two  or  three  weeks,  the  rate  in  some  cases 
being  as  low  as  40  or  30. 

The  Heart. — Myocarditis  sometimes  occurs.  In  protracted  cases  the 
heart  muscles  become  soft  and  flabby  to  a  variable  extent,  but  the  fibers 
show  little  or  no  change  microscopically,  except  a  granular  degeneration 
in  some  instances.  Fatty  or  hyalin  degeneration  is  found  only  in  the 
most  protracted  cases  and  in  association  with  jjrofound  anemia.  Other 
degenerations  are  rare. 

Endocarditis  is  one  of  the  rarest  complications.  It  is  attributable  to 
the  direct  action  of  the  toxin  upon  the  endocardium. 

Pericarditis  is  infrequent  and  is  found  almost  exclusively  in  children 
or  associated  with  pneumonia.  Two  cases  of  suppurative  pericarditis 
are  recorded. 

The  heart-sounds  often  remain  normal,  but  in  asthenic  cases  the  first 
sound  becomes  weak  and  may  become  inaudible.  In  extreme  weakness 
the  first  and  second  sounds  become  much  alike  and  the  long  interval 
"becomes  shortened  (embryocardia).  A  soft  blowing  murmur  may  re- 
place the  first  sound.  The  systolic  impulse  becomes  feeble  and  some- 
times imperceptible. 

Tlie  Arteries. — Thrombosis  and  embolism  are  not  common,  but  some- 
times cause  obliteration  of  one  or  more  arterial  trunks.  They  generally 
form  during  the  second  or  third  week,  sometimes  during  convalescence. 
When  the  femoral  artery  is  closed,  the  circulation  of  the  leg  and  foot  is 
arrested,  and  gangrene  of  the  foot  and  leg  may  result,  as  in  the  remark- 
able case  recently  recorded  by  Nammack.  In  a  few  instances  both  femo- 
rals  have  been  obliterated.  Embolism  is  thought  to  be  a  result  of  frag- 
mentation and  detachment  of  clots  formed  in  the  dilated  cavities  of 
the  weakened  heart,  favored  by  the  increased  coagulability  of  the  blood. 
Infarcts  are  sometimes  found  in  the  kidneys,  spleen,  and  lungs,  in 
association  with  arterial  thrombosis. 

The  Veins. — Venous  thrombosis  is  a  complication  in  about  one  per 
cent  of  cases,  occurring  most  frequently  in  the  veins  of  the  lower  ex- 
tremities, especially  in  the  left  femoral,  rarely  in  the  popliteal.  It  gen- 
eraHy  develops  during  convalescence.  Its  more  frequent  occurrence  on 
the  left  side  has  been  attributed  to  the  slight  pressure  of  the  left 
common  iliac  artery  upon  the  vein  at  the  point  of  crossing.  The  clots 
are  sometimes  remarkable  in  size,  extending  from  the  deep  femoral, 
through  the  iliac,  into  the  vena  cava.  The  fact  that  the  bacilli  have 
been  found  in  the  walls  of  the  affected  veins  and  in  the  clot  suggests 
the   probability   that  the  coagulation  is   due  to  local  infection  of  the 


TYPHOID  FEVER  59 

wall  of  the  vein.  As  a  result  of  the  thrombosis,  the  leg  becomes  much 
swollen,  painful,  and  tender ;  convalescence  is  prolonged,  and  permanent 
disability  may  remain.  Gangrene  of  the  leg  has  been  observed  in  a  few 
instances,  but  perhaps  not  solely  as  a  result  of  the  venous  obstruction. 
Thrombotic  obliteration  of  the  left  iliac  vein  has  been  followed  by  sudden 
death.  Thrombosis  may  involve  also  the  cerebral  sinuses  and  very 
rarely  the  veins  of  the  upper  extremities.  Symmetrical  gangrene  sugges- 
tive of  Raynaud's  disease  has  been  seen.  Thyroiditis  has  been  observed 
during  convalescence. 

.  The  spleen  is  enlarged  to  such  an  extent  that,  by  the  end  of  the  first 
week,  it  can  generally  be  felt  below  the  margin  of  the  ribs,  unless,  as 
is  frequently  the  case,  it  is  pushed  back  by  the  distended  colon.  In  this 
condition  the  dullness  may  be  unrecognizable  on  percussion.  By  the 
end  of  the  third  week  it  usually  becomes  reduced  in  size.  Sometimes 
in  elderly  patients  and  generally  after  profuse  hemorrhage,  it  is  of  small 
size.  Owing  to  its  friability,  it  may  be  ruptured  by  a  blow,  or,  possibly, 
by  too  forcible  palpation,  as  noted  by  Bartholow.  Spontaneous  rupture 
sometimes  occurs.     Hemorrhagic  infarction  may  be  found  at  autopsy. 

Digestive  System. — Complete  loss  of  appetite  (anorexia)  is  general-ly 
one  of  the  earliest  symptoms  and  the  appetite  does  not  return  until 
several  days  after  the  fever  has  subsided.  During  convalescence  it  often 
becomes  ravenous.  Thirst  is  constant.  In  the  height  of  the  fever,  when 
the  demand  for  liquids  is  greatest,  the  patient  rarely  asks  for  drink, 
owing  to  his  mental  dullness,  although  he  drinks  with  avidity  the  liquids 
that  are  put  to  his  lips. 

The  tongue  is  generally  moist,  but  coated  with  a  thin  white  fur  during 
the  incubation.  It  is  often  tremulous  when  protruded.  During  the  first 
week  it  becomes  slightly  swollen,  the  coat  heavier  and  usually  of  a 
yellowish  color,  except  at  the  tip,  which  is,  as  a  rule,  clean  and  of  a 
bright  red  color.  This  appearance  may  persist  throughout  the  course 
of  the  disease,  but  in  most  cases  by  the  end  of  the  second  week  the 
mouth  and  tongue  become  excessively  dry,  partly  owing  to  a  deficiency 
of  saliva,  and  the  coating  often  becomes  dark  brown.  Catarrhal  stoma- 
titis may  develop.  If  the  patient  breathes  through  the  mouth,  the  dry- 
ness becomes  extreme,  the  coating  almost  black,  and  deep  fissures  are 
formed.  A  similar  coating  (sordes)  often  forms  on  the  teeth  and  lips. 
The  condition  of  the  lips  is  often  aggravated  by  the  patient's  picking. 
As  convalescence  becomes  established,  the  moisture  returns  to  the  mouth 
and  the  tongue  loses  its  coating.  In  some  cases,  especially  in  children, 
the  tongue  remains  clean  throughout  the  disease. 

The  fauces  and  pharynx  often  become  dry  and  red,  as  in  scarlatina, 
or  coated  with  a  tenacious  mucus  that  interferes  with  swallowing. 
Occasionally  ulcers  form,  and  a  fatal  membranous  pharyngitis  has  been 
observed  in  the  third  week.  Thrush  sometimes  arises  as  a  complication 
and  may  extend  from  the  mouth  into  the  esophagus.  Noma  has  also 
been  observed,  affecting  either  the  cheek  or  the  genitalia. 

Otitis  media  may  arise  from  extension  of  inflammation  through  the 
Eustachian  tube. 

The  Parfllid  (JA?/?!/.— Complications  on  the  part  of  the  parotid  gland 
occur  in  some  cases.  The  inflammation  is  usually  suppurative  and  con- 
fined to  one  side.    It  is  more  liable  to  develop  during  convalescence. 


6o  PRACTICE  OF  MEDICINE 

The  infection  may  be  either  by  extension  through  Steno's  duct  or  by 
metastasis.  Some  authors  regard  the  condition  as  highly  fatal.  The 
submaxillary  gland  may  be  similarly  affected. 

Vomiting  is  not  a  frequent  symptom.  It  may  occur  early,  however, 
especially  in  children,  and  sometimes  persists  throughout  the  disease. 
Repeated  vomiting  during  the  second  and  third  weeks  may  indicate 
the  development  of  peritonitis,  nephritis,  gastric  ulcer,  or  a  cerebral 
lesion.     It  has  proved  fatal  in  a  few  instances. 

Chronic  gastritis  and  dilatation  of  the  stomach  have  been  attributed 
to  a  preceding  attack  of  typhoid  fever.  Keen  reports  two  cases  of  eso- 
phageal stricture  apparently  due  to  cicatrization  of  typhoid  ulcers  in 
this  unusual  location. 

Diarrhea. — There  is  probably  no  one  symptom  of  typhoid  fever  which 
shows  so  much  variance  as  this,  or  in  regard  to  which  so  much  diver- 
sity of  opinion  has  existed.  Probably,  as  Thompson  remarks,  it  is  less 
common  and  less  severe  than  formerly.  It  is  absent  throughout  the 
disease  in  fully  half  the  cases  and  is  rarely  severe.  It  is  probably  a 
more  prominent  feature  when  the  follicles  of  the  large  intestine  are  in- 
volved; but  neither  its  presence  nor  its  absence  can  be  regarded  as  a 
reliable  indication  of  the  extent  of  intestinal  involvement.  Diarrhea 
usually  develops  by  the  end  of  the  first  week,  but  it  may  not  begin 
until  the  third  or  fourth.  The  number  of  discharges  seldom  exceeds 
three  or  four  a  day,  but  may  reach  ten  or  more.  The  stools  are  alka- 
line, usually  of  a  grayish  yellow  color,  often  not  unlike  the  normal 
contents  of  the  small  intestine,  though  more  offensive.  They  separate, 
on  standing,  into  a  thin  supernatant  layer  containing  albumin  and  salts, 
and  a  lower,  flocculent,  layer  containing  epithelial  debris,  numerous 
triple  phosphate  crystals,  and  remnants  of  food.  Sloughs  from  the 
follicles  may  be  found  in  them  about  the  end  of  the  second  week.  Micro- 
scopic examination  reveals  also  numerous  micro-organisms  of  different 
kinds  and  sometimes  blood-cells.  The  typhoid  bacilli  are  found  in  great 
numbers,  as  a  rule,  after  the  middle  of  the  first  week  or  beginning  of  the 
second. 

Constipation  not  infrequently  prevails  throughout  the  entire  course 
of  the  disease.  In  the  experience  of  not  a  few  writers  it  is  the  more 
usual  condition.  It  occasionally  becomes  extreme,  and  fecal  impaction 
with  more  or  less  complete  obstruction  of  the  bowel  has  resulted  in  a 
few  instances. 

Meteorism  or  abdominal  distention  of  moderate  degree  is  present 
in  most  cases,  especially  during  the  second  week,  the  weakened,  edem- 
atous, and  probably  paretic  condition  of  the  intestinal  walls  favoring 
the  accumulation  of  gas.  When  extreme  it  is  one  of  the  most  alarming 
and  dangerous  complications,  preventing  the  healing  of  ulcers,  favoring 
the  production  of  perforation,  and  interfering  with  the  action  of  the 
heart  and  lungs.  The  intestinal  distention  is  thought  also  to  favor 
the  absorption  of  the  products  of  food-decomposition  and  thus  to  in- 
crease the  fever.  It  sometimes  develops  during  convalescence  as  a 
result  of  a  too  liberal  diet. 

Abdomiiial  te?iderness  and  gurgling  in  the  right  iliac  fossa  are  present 
in  most  cases,  and  although  they  are  by  no  means  pathognomonic, 
they  are  of  some  diagnostic  importance,  indicating  the  presence  of  fluid 


TYPHOID  FEVER  6i 

feces  and  gas  in  the  cecum  and  colon.  Spontaneous  pain  does  not 
usually  occur,  and  it  is  generally  confined  to  the  iliac  fossa.  It  may  be  so 
severe  as  to  cause  a  suspicion  of  appendicitis,  especially  when  associated 
with  tenderness.  In  children  the  pain  and  tenderness  are  often  referred 
to  the  umbilicus. 

Intestinal  he7norrhage  occurs  in  from  3  to  lo  per  cent  of  all  cases, 
and  it  proves  fatal  in  from  30  to  50  per  cent  of  the  cases  in  which 
it  occurs.  It  generally  develops  at  the  time  the  sloughs  separate  from 
the  ulcers,  toward  the  end  of  the  second  week  or  in  the  third;  more 
frequently  in  cases  that  have  run  a  severe  course,  but  sometimes  in  the 
mildest.  The  hemorrhage  generally  comes  on  without  warning.  The 
patient  suddenly  sinks  into  a  state  of  collapse,  with  pallor,  restlessness, 
a  sense  of  suffocation,  cold  extremities,  and  profuse  cold  sweat.  The 
temperature  declines  rapidly,  sometimes  dropping  six  or  eight  degrees 
in  a  few  hours  and  becoming  subnormal.  The  pulse  becomes  extremely 
weak,  often  entirely  fading  away.  Death  may  supervene  before  the  blood 
has  left  the  bowel.  WTien  recovery  occurs,  the  discharges  may  continue 
to  contain  offensive  dark  clots  for  several  days.  Intestinal  hemorrhage, 
like  excessive  epistaxis,  may  result  from  a  natural  tendency  to  bleed 
(hemophilia).  It  is  important,  in  cases  of  supposed  moderate  intestinal 
hemorrhage,  to  exclude  the  bleeding  of  internal  hemorrhoids. 

Perforation  of  the  bowel  is  an  exceedingly  dangerous  complication  and 
is  responsible  for  from  2  to  3  per  cent  of  the  mortality.  The  perfora- 
tion is  most  frequently  located  in  the  ileum,  next  in  the  cecum  or  colon, 
but  it  has  been  found  in  the  jejunum.  The  time  of  its  greatest  liability 
is  from  the  end  of  the  second  week  to  the  beginning  of  the  fourth,  but  it 
has  been  observed  as  early  as  the  eighth  day  or  late  in  the  convales- 
cence, even  in  the  sixteenth  week.  It  is  more  frequent  in  men  and  rare 
in  childhood  or  after  the  fortieth  year.  It  is  more  apt  to  occur  in 
cases  that  have  run  a  violent  course,  marked  by  profuse  diarrhea  and 
great  abdominal  distention,  but  it  is  not  infrequently  seen  in  mild, 
ambulatory  cases.  The  cause  of  the  perforation  cannot  usually  be  de- 
termined. Too  active  movements,  as  getting  out  of  bed;  improper  food, 
meteorism,  and  vomiting  may  induce  it.  A  lumbricoid  worm  has  been 
found  in  the  peritoneal  cavity  after  perforation  and  the  accident  has 
been  attributed  to  the  parasite.  Cold  bathing  has  been,  perhaps  un- 
justly, censured  as  a  possible  cause. 

The  immediate  result  of  perforation  is  the  escape  of  the  intestinal 
contents  into  the  peritoneal  cavity.  This  gives  rise  to  an  acute  septic 
peritonitis  that  speedily  becomes  generalized.  In  a  few  instances  the 
inflammation  has  remained  circumscribed  and,  by  forming  adhesions, 
has  shut  off  the  portion  nearest  the  opening  and  thus  prevented  an 
involvement  of  the  general  peritoneum.  Intestinal  hemorrhage  is  not 
infrequently  associated  with  perforation. 

The  first  indication  that  perforation  has  occurred  is,  in  most  cases, 
a  sudden,  severe  pain  in  the  abdomen,  immediately  followed  by  collapse, 
great  weakness,  pinched  features,  and  generally  a  small  rapid  pulse. 
The  abdomen  becomes  greatly  distended  and  sensitive,  the  breathing  is 
impeded.  The  legs  are  generally  drawn  up  to  relieve  the  tension  of  the 
abdominal  walls.  Nausea  and  vomiting  generally  ensue  upon  the  begin- 
ning  of  inflammation,    and    may    persist    until    the    patient   becomes 


62  PRACTICE  OF  MEDICINE 

exhausted.  In  another  group  of  cases  the  accident  is  followed  by  no 
distinctive  symptoms,  or  the  onset  is  so  gradual  as  to  escape  observa- 
tion. This  is  especially  the  case  when  the  perforation  occurs  late  in  a 
case  that  has  been  characterized  by  delirium  or  coma.  Percussion  re- 
veals an  obliteration  of  the  splenic  and  hepatic  dullness,  a  sign  belonging 
also  to  intestinal  distention.  The  most  valuable  diagnostic  feature  in 
most  cases  is  the  development  of  leucocytosis.  It  is  of  value,  however, 
only  in  the  absence  of  suppuration  or  other  complications.  The  abdo- 
men may  remain  flat  and  hard,  the  patient  soon  passes  into  a  moribund 
state,  and  the  lesion  is  found  after  death.  In  some  instances  the  first 
shock  terminates  fatally;  but  when  death  is  due  to  pertonitis,  it  gener- 
ally occurs  on  the  third  or  fourth  day  after  perforation. 

A  circumscribed  peritonitis  not  infrequently  occurs  independently  of 
perforation,  and  occasionally  it  becomes  generalized.  It  is  a  result  of 
the  extension  to  the  overlying  peritoneum  of  the  inflammation  from  the 
ulcers;  from  a  suppurating  infarct  of  the  spleen  or  kidney,  or  rupture 
of  the  gall-bladder.  Localized  peritonitis  of  this  character  is  rarely  di- 
agnosticated; it  is  recognized  post-mortem  by  the  adhesions  that  have 
resulted.  A  fatal  case  of  chronic  follicular  colitis  with  villous  outgrowth 
was  observed,  a  few  weeks  after  the  fever,  by  Thompson.  Abscesses 
sometimes  form  in  the  mesenteric  glands,  producing  sepsis,  perforation 
of  the  colon,  rectum,  or  vagina,  or  fatal  erosion  of  a  blood-vessel. 

The  ZzWr.— Complications  on  the  part  of  the  liver  are  not  frequent. 
Particularly  is  this  true  of  single  abscess-formation.  Pylephlebitis  is 
more  common,  and  suppurative  colangitis  has  been  seen.  Necrotic  foci 
frequently  occur,  but,  although  they  are  sometimes  numerous,  they  are 
ordinarily  of  little  importance  and  are  replaced  by  new  connective  tissue. 
They  are  attributed  to  the  action  of  the  typhoid  toxin. 

Jaundice  sometimes  occurs  and  ma}^  be  a  result  of  toxemia,  catarrh 
or  ulceration  of  the  bile  passages,  the  presence  of  calculi,  or  an  exten- 
sive necrosis  of  hepatic  cells.  As  previously  noted,  the  mucous  membrane 
of  the  gall-bladder  is  a  favorite  nidus  for  the  growth  of  the  typhoid 
bacillus.  In  some  cases  they  cause  no  disturbance,  while  in  others  they 
give  rise  to  suppuration,  perforation,  and  resultant  peritonitis.  These 
disturbances  are  sometimes  delayed  until  weeks  or  months  after  ap- 
parent recovery.  The  rather  frequent  occurrence  of  gall-stones  after 
typhoid  fever  has  been  attributed  to  this  persistence  of  the  bacilli  in 
the  gall-bladder. 

Respiratory  System. — Epistaxis  is  of  so  common  occurrence  during 
the  incubation  or  invasion  as  to  be  a  symptom  of  diagnostic  value. 
It  is  sometimes  profuse,  especially  in  the  presence  of  the  hemorrhagic 
diathesis,  and  it  has  proved  a  serious,  even  fatal,  complication.  The 
entire  respiratory  mucous  membrane  may  become  inflamed. 

The  larynx  is  not  often  the  seat  of  complications,  but  simple  and  ul- 
cerative laryngitis,  edema  often  associated  with  ulcer,  and  perichondri- 
tis have  been  observed.  Stenosis  may  follow.  Paralysis  of  the  laryngeal 
muscles,  due  to  neuritis,  has  been  noted. 

Bronchitis  is  present  in  nearly  all  cases.  Although  the  cough  is  often 
so  slight  as  to  cause  little  annoyance,  auscultation  reveals  sibilant  rales. 
It  is  seldom  a  serious  complication  except  in  children  and  the  aged, 
in  whom  it  may  lead  to  lobular  pneumonia.     This  aftection  is  rendered 


TYPHOID   FEVER  63 

somewhat  more  dangerous  in  this  connection  by  a  tendency  to  suppura- 
tion or  gangrene.  Perforation  of  the  pleura  with  resultant  pyopneumo- 
thorax may  follow  the  formation  of  a  pus  cavity. 

Lobar  pneumonia  is  a  more  frequent  complication.  It  sometimes 
develops  before  the  typhoid  infection  has  manifested  itself  and  may  have 
nearly  run  its  course  before  the  latter  disease  has  been  recognized.  The 
crisis  is  usually  prevented  by  the  typhoid  infection.  In  other  instances, 
the  pneumonic  consolidation  occurs,  sometimes  after  chill,  and  usually 
with  some  increase  of  temperature,  during  the  second  or  third  week 
of  the  fever  or  later.  It  then  constitutes  a  most  dangerous  com- 
plication. The  symptoms  of  pneumonia  are  sometimes  so  light  or  so 
obscured  that  the  condition  is  probably  often  overlooked.  Whether 
the  pneumonia  is  induced  by  the  typhoid  bacillus  or  is  due  to  a  specific 
organism  has  not  been  determined. 

Hypostatic  congestion  and  edema  of  the  lungs  are  generally  associated. 
They  occur  to  a  variable  extent  in  the  posterior  portions  of  both  lungs, 
in  a  large  proportion  of  cases,  as  a  result  of  enfeebled  circulation  and 
the  dorsal  decubitus  which  the  patient  is  probably  too  often  permitted 
to  occupy.  Hemoptysis  has  occurred  during  the  course  of  the  disease 
in  a  few  instances. 

The  Nervous  System. — The  effect  of  the  typhotoxin  upon  the  nervous 
system  is  a  pronounced  feature  of  the  fever  in  most  cases.  Head- 
ache, usually  temporal  or  occipital,  sometimes  general,  predominates 
in  the  first  week.  It  is  occasionally  accompanied  by  vertigo  and  in  aggra- 
vated cases  by  pain  in  the  back  of  the  neck  and  in  the  dorsal  region. 
These  symptoms  may  be  associated  with  retraction  of  the  head,  photo- 
phobia, ■  and  muscular  twitching  or  rigidity,  suggestive  of  meningitis. 
Such  cases  are  classified  by  some  authors  as  belonging  to  a  cerebro- 
spinal form  of  the  disease.  The  symptoms  probably  depend  for  the  most 
part  upon  the  action  of  the  toxin,  although  the  bacilli  have  repeatedly 
been  found  in  the  meninges  after  death.  The  anatomical  lesions  are 
generally  limited  to  a  hyperemia  of  the  pia  mater  of  the  brain  and  cord. 

Meningitis  is,  however,  one  of  the  least  frequent  complications  and  is 
manifested  by  convulsions,  opisthotonos,  photophobia  strabismus,  dis- 
turbance of  the  cranial  nerves  and  usually  by  an  increase  of  fever  with 
diminution  or  obliteration  of  the  morning  remission.  Wakefulness  and 
restlessness,  especially  at  night,  arc  prominent  during  the  first  week,  but 
somnolence  and  apathy  soon  develop,  as  a  rule,  and  the  patient  passes 
most  of  his  time  in  sleep.  But  his  rest  is  not  refreshing.  The  hebetude 
is  generally  so  marked  that  the  patient  must  be  aroused  for  the 
administration  of  nutriment  and  drink,  and  immediately  after  partak- 
ing of  them  he  falls  into  his  former  state  of  indifference.  Convulsions 
rarely  occur  except  at  the  beginning  of  the  attack,  and  then  only  in 
children,  or  at  the  onset  of  complications  or  intercurrent  diseases.  They 
are  somewhat  more  frequent,  however,  in  alcoholic  subjects. 

Delirium  is  not  so  often  seen  as  it  was  before  the  adoption  of  present 
methods  of  treatment.  Delirium  of  a  few  moments'  duration  is  not 
infrequent,  especially  at  night  or  just  after  awaking  from  sleep.  It 
may  assume  several  forms.  When  it  is  mild,  the  patient  often  mutters 
especially  when  he  is  alone,  or  he  may  be  quietly  delirious  at  all  times. 
A  worse  form  is  accompanied  with  tremors,  twitching  of  the  muscles 


64  PRACTICE  OF  MEDICINE 

of  the  face,  jerking  of  the  tendons  of  the  fingers  and  wrists  (subsultus 
tendinum),  picking  at  the  bedclothes  or  at  imaginary  objects  in  the  air 
(carphology),  and  attempts  to  get  out  of  bed.  These  patients  have  re- 
peatedly escaped  at  an  unguarded  moment  and  the  result  has  frequently 
been  disastrous.  The  tremulousness  and  delusions  are  much  like  those 
of  delirium  tremens,  and  they  are  more  apt  to  occur  in  alcoholic  sub- 
jects. They  sometimes  assume  a  hysterical  aspect.  In  the  worst  cases, 
the  patient  sinks  into  a  state  of  unconsciousness,  is  oblivious  to  his 
surroundings,  and  cannot  be  fully  aroused.  The  urine  and  feces  may 
pass  involuntarily.  Or  the  condition  may  be  one  of  coma-vigil,  in  which 
the  patient  lies  with  open  eyes,  apparently  seeing,  often  following  the 
movements  of  his  attendant,  although  he  is  entirely  unconscious.  As 
Niemeyer  expressed  it,  he  lives  in  an  excited  dream.  These  are  the  most 
fatal  cases,  and  no  doubt  represent  the  highest  degree  of  toxemia. 

Theodore  Diller  reports  a  case  of  meningomyelitis  following  the  dis- 
ease in  a  girl  of  15^2  years,  and  affecting  the  cord  from  about  the 
eleventh  thoracic  segment  down.  The  paralysis  of  the  legs,  bladder, 
and  bowel  was  complete  for  two  months,  then  gradually  improved. 

Neui'itis  is  not  uncommon  and  may  develop  during  the  height  of  the 
disease  or  not  until  after  convalescence.  It  may  be  local  or  generalized. 
It  sometimes  sets  in  with  excruciating  pain  and  great  hyperesthesia  of 
the  nerve  trunks  or  muscles  of  one  arm  or  leg,  affecting  especially  the 
extensors,  in  which  form  it  leaves  more  or  less  permanent  wrist-drop  or 
foot-drop.  Another  form  of  neuritis  has  ensued  upon  a  week  or  two  of 
the  cold-bath  treatment.  It  produces  the  "tender  toes"  first  described 
by  Hanford,  in  which  the  pads  of  the  toes  become  extremely  sensitive 
to  pressure. 

Multiple  fieuritis,  especially  of  a  paraplegic  type,  sometimes  develops 
during  convalescence,  affecting  any  one  of  the  extremities  or  all  four. 
The  symptoms  resemble  those  of  multiple  polyomyelitis,  and  paraplegia 
or  an  atrophic  paralysis  of  a  single  extremity  may  remain. 

Acute  anterior  polyomyelitis  has  been  met  with  as  a  complication, 
particularly  in  children,  and  associated  with  a  gradually  ascending 
paralysis,  often  fatal  in  a  few  days.  Hemiplegia,  from  hemorrhage  or 
encephalitis,  is  rare,  coming  on  during  convalescence.  It  may  be  accom- 
panied with  choreic  movements,  or  aphasia  when  the  right  side  is  af- 
fected. Recovery  is  the  rule  in  children.  True  tetanic  attacks  are  to  be 
classed  with  the  rarest  complications. 

Following  typhoid  fever,  mental  disturbances  may  remain  for  a  time; 
the  most  common  are  loss  of  memory  and  melancholia.  Insanity,  us- 
ually of  the  confusional  type,  may  develop  in  persons  predisposed  to  it. 
Acute  mania  is  occasionally  encountered.  Epilepsy  also  seems  to  be 
brought  out  in  some  cases.  Brain  abscess  due  to  the  bacillus  typhosus 
has  been  observed. 

The  typhoid  spine,  which  was  first  described  by  Gibney,  as. probably 
due  to  perispondylitis,  an  acute  inflammation  of  the  periosteum  and 
of  the  fibrous  structures  which  bind  the  vertebra;  together,  is  regarded 
by  Osier  as  a  neurosis.  It  usually  develops  several  weeks  after  the 
fever  has  subsided  and  may  follow  a  jar  or  shock.  It  is  not  attended 
with  fever  or  other  signs  of  inflammation.  The  symptoms  are  chiefly 
of  a  hysterical  nature. 


TYPHOID  FEVER  65 

Organs  of  Special  Sense. — Conjunctivitis  and  keratitis,  sometimes 
with  phlyctenuiae,  and  iritis  and  choroiditis  are  occasional  comph- 
cations  on  the  part  of  the  eye.  Panophthalmitis  is  exceedingly  rare. 
Dilatation  of  the  pupil  is  common;  temporary  paralysis  of  accommo- 
dation is  not  infrequent.  Paralysis  of  the  external  muscles  of  the  eye 
is  sometimes  met  with  during  convalescence,  probably  as  a  result  of 
neuritis.  Retinal  hemorrhage,  alone  or  accompanying  other  hem- 
orrhages, is  more  frequent,  according  to  De  Schweinitz,  than  is  generally 
realized.  Profuse  retinal  hemorrhage  is  rare,  but  amaurosis  sometimes 
develops  after  severe  intestinal  hemorrhage,  and  the  blindness  is  some- 
times permanent. 

Single  or  double  optic  neuritis  may  develop  independently  of  menin- 
gitis, and  is  generally  followed  by  atrophy  of  the  optic  nerve.  Cata- 
ract has  been  noted  as  a  sequel  of  typhoid  fever.  Trelat  records  the 
occurrence  of  double  cataract  in  two  cases.  Orbital  hemorrhage  and 
thrombosis  of  the  veins  of  the  orbit  are  possible  complications. 

Otitis  media  occurs  in  about  2.5  per  cent,  of  cases,  but  recovery  is 
generally  prompt  without  involvement  of  the  mastoid  cells. 

Renal  System. — There  is  the  usual  febrile  concentration  of  the  urine, 
with  increase  of  specific  gravity  and  color.  As  the  fever  declines,  the 
quantity  is  increased  and  the  density  diminished.  The  chlorids,  on  the 
other  hand,  are  reduced  during  the  febrile  stage  and  increased  when  the 
elimination  becomes  more  abundant.  Retention  of  the  urine  is  often 
an  early  symptom  and  may  recur  periodically.  During  the  somnolent 
state,  the  patient  seldom  expresses  a  desire  to  urinate,  and  a  careless 
nurse  may  permit  the  bladder  to  become  distended.  Pain  and  restless- 
ness are  produced.     Incontinence  may  occur  during  delirium. 

Febrile  albuminuria  is  observed  in  nearly  a  third  of  all  cases.  The 
urine  contains  also,  in  nearly  all  cases,  an  undetermined  substance  which 
yields  a  peculiar  yellow  color  in  the  diazo  reaction  (see  p.  734).  Acute 
nephritis  occasionally  develops,  i.  It  may  occur  at  the  onset  of  the 
disease,  producing  a  type  to  which  German  authors  give  the  name 
nephrotyphoid.  The  passage  of  scanty,  bloody  urine  at  this  time  some- 
times masks  typhoid  infection,  which,  developing  later,  may  be  for  a 
time  regarded  as  uremic  in  character.  2.  Developing  during,  the  height 
of  the  fever,  especially  during  the  beginning  of  the  second  week,  nephritis 
often  escapes  recognition,  but  should  be  recognized  by  the  presence  of 
albumin,  casts,  blood,  and  epithelium.  3.  As  a  sequel,  nephritis  is  gen- 
erally promptly  recognized,  on  account  of  the  production  of  edema. 
It  is  not  usually  serious  in  its  results.  The  lymphomatous  nephritis  of 
Wagner  is  not  attended  by  symptoms.  Pyuria  has  been  noted,  some- 
times early,  sometimes  as  late  as  the  twenty-eighth  day.  The  origin 
of  the  pus  is  obscure.  The  colon  bacillus  was  found  in  the  pus  of  seven, 
the  typhoid  bacillus  in  two,  and  the  staphylococcus  albus  in  one  of 
Osier's  cases.  Suppurative  pyelitis  is  rare.  It  may  be  membranous 
at  first  and  associated  with  membranous  inflammation  of  the  bladder. 
Later  the  membrane  gives  place  to  an  erosion  and  ulceration.  Hema- 
turia is  usually  associated  with  acute  nephritis,  but  may  occur  indepen- 
dently; the  blood  is  of  renal  origin.  In  some  cases  hemoglobin  alone  is 
found.  The  toxicity  of  the  urine  is  increased  throughout  the  entire 
•course  of  the  disease  and  convalescence. 


66  PRACTICE  OF  MEDICINE 

Cystitis  may  occur  later  in  the  disease  or  during  convalescence,  es- 
pecially as  ■  a  result  of  retention  or  from  infection  by  unclean  catheters. 

Urethritis  is  reported  to  have  originated  spontaneously  during  con- 
valescence in  a  few  cases  in  which  other  organisms  than  the  gonococcus 
were  present.  Orchitis  and  epididymitis,  separately  or  together,  have 
also  been  observed.  They  are  attributed  by  Keen  to  a  pure  typhoid 
infection.  Abscess  of  the  ovary,  of  the  same  character,  has  been  noted. 
Gangrene  of  the  genitalia  (noma)  has  occurred  in  a  few  cases,  chiefly 
in  women. 

The  Typhoid  Eruption. — The  characteristic  eruption  is  a  rose-colored 
rash  which  ordinarily  makes  its  appearance  on  the  seventh  or  eighth 
day,  but  sometimes  as  late  as  the  tenth  or  twelfth.  It  generally  consists 
of  not  more  than  a  dozen  distinct,  round  or  lenticular,  slightly  elevated 
papules  flattened  on  top,  from  2  to  4  mm.  in  diameter,  occasionally 
showing  small  vesicles  in  the  center,  sometimes  petechial  or  dark  in  color. 
It  appears  first  on  the  upper  part  of  the  abdomen  and  lower  part  of 
the  thorax,  sometimes  on  the  back  and  thighs.  When  the  spots  are 
numerous  they  may  be  found  also  on  the  extremities,  rarely  on  the  face, 
Successive  crops  develop,  each  persisting  two  or  three  days,  and  they 
sometimes  leave  brownish  pigmentation.  They  can  often  be  felt  with 
the  finger,  and,  when  touched,  vanish,  but  quickly  reappear  after  the 
pressure  is  removed.  They  are  rarely  to  be  found  after  the  middle  of 
the  third  week.  They  are  occasionally  absent,  particularly  in  children 
and  old  people. 

Erythema,  a  scarlet-colored  rash,  sometimes  appears  early,  especially 
on  the  thorax  and  abdomen,  rarely  extending  to  the  extremities.  Urti- 
caria, papular  eczema,  and  purpura  hemorrhagica  have  been  encountered. 
Herpes  may  appear  on  the  lips,  but  is  less  frequent  than  in  other  fevers. 
Peliomata,  peculiar,  pale  blue,  subcuticular  spots  of  irregular  outline 
and  from  4  to  10  mm.  in  diameter,  are  sometimes  seen.  They  are  be- 
lieved to  be  due  to  the  presence  of  pediculi  and,  therefore,  bear  no  relation 
to  the  disease. 

Tache  cei-'ebrale  is  the  name  given  to  the  red  line  with  white  margins 
which  appears,  especially  in  nervous  subjects,  after  the  finger-nail  has 
been  drawn  over  the  skin.  It  is  not  peculiar  to  this  disease.  Osier 
calls  attention  to  a  pinkish,  sometimes  mottled  appearance  of  the  skin 
of  the  abdomen  and  arms  that  is  seen  in  some  cases  when  exposed  to 
the  air. 

Ecchymoses  rarely  appear  except  in  connection  with  the  hemorrhagic 
diathesis  or  on  the  dependent  portions  of  the  body  in  a  moribund  case. 
The  palms  and  soles  often  become  dry  and  harsh,  apparently  thickened. 
More  or  less  general  edema  may  occur  as  a  result  of  anemia,  or  locally 
after  obstruction  of  the  circulation,  as  by  thrombosis.  It  is  also  an 
important  symptom  of  nephritis  in  a  later  stage  of  the  disease. 

Bedsores  occur  for  the  most  part  in  emaciated  subjects,  or  after 
protracted  fever.  They  are  not  so  frequently  seen  since  cleanly  methods 
of  nursing  have  been  adopted.  They  may  occur,  however,  under  the 
most  careful  supervision,  as  a  result  of  profound  trophic  disturbance, 
or  when  the  vitahty  of  the  skin  has  been  impaired  by  one  of  the  eruptive 
disorders.  They  occur,  as  a  rule,  over  the  sacrum  or  buttocks,  but  some- 
times  over  other  prominences,  the  shoulders,  spinous  processes,  elbows. 


TYPHOID  FEVER  67 

heels,  and  occiput.  Rarely  they  appear  in  places  not  subjected  to  pres- 
sure. Gangrene,  as  previously  stated,  is  generally  a  result  of  throm- 
bosis or  embolism. 

Boils  and  abscesses  are  not  infrequent  sequelae,  resulting  from  pyog- 
enic infection  of  the  skin,  especially  of  the  axillge,  back,  buttocks,  arms, 
or  legs.  Curschmann  thinks  that  they  are  more  frequent  after  the  cold- 
bath  treatment.  They  are  sometimes  so  numerous  as  to  greatly  weaken 
the  patient  and  prolong  convalescence.  They  may  continue  to  appear 
for  a  month  or  more  after  recovery.  As  a  result  of  these  suppurative 
affections,  the  pus-forming  cocci  sometimes  gain  access  to  the  blood  and 
produce  pyemia.  It  is  quite  probable,  indeed,  that  in  many  cases  the 
multiple  abscesses  are  themselves  the  result  of  pyemic  infection. 

Atrophic  lines  are  sometimes  left  in  the  skin  of  the  abdomen  and 
sides  of  the  thighs  similar  to  those  produced  by  pregnancy.  They  are 
probably  due  to  neuritis. 

Sweats. — During  the  height  of  the  fever,  the  skin  is  generally  dry 
and  hot;  sweating  is  rare.  The  chest  and  abdomen  may,  however, 
become  moist  for  a  while  after  a  bath.  A  sudoral  form  of  the  disease, 
characterized  by  profuse  sweating,  is  described  by  French  writers.  Chills 
occurring  during  the  course  of  the  disease  are  sometimes  followed  by 
sweating  similar  to  that  at  the  close  of  a  malarial  paroxysm,  although 
no  malarial  infection  is  present.  A  suspicion  of  sepsis  often  is  aroused. 
During  defervescence,  however,  sweating  is  more  common.  Sudaminal 
and  miliarial  eruptions  are  occasionally  seen  in  cases  characterized  by 
free  sweating.  They  are  generally  limited  to  the  axillae,  abdomen,  and 
inner  sides  of  the  thighs.  They  sometimes  terminate  in  a  desquamation 
in  the  form  of  flakes  or  large  pieces,  especially  in  children. 

A  peculiar  odor  is  frequently  noticeable;  possibly  it  is  a  cutaneous 
exhalation.  It  sometimes  appears  to  be  an  exaggeration  of  the  individ- 
ual odor,  but  in  some  cases  it  is  better  described  by  Nathan  Smith  as 
a  "  semi-cadaveric"  smell. 

Alopecia. — The  loss  of  hair,  which  is  almost  universal  during  recovery 
from  typhoid  fever,  may  be  slight  or  it  may  reach  the  degree  of  bald- 
ness. It  is  generally  confined  to  the  head,  rarely  affecting  the  beard 
or  other  parts  of  the  body.  The  hair  is  generally  fully  restored,  but 
in  some  cases  the  growth  is  lighter  and  other  characteristics  may  be 
altered. 

Muscles,  Bones  and  Joints. — The  muscles  are  generally  atrophied. 
Granular,  fatty,  or  hyalin  degeneration  sometimes  occurs.  As  a  result, 
especially  of  the  last  form  of  degeneration,  the  muscles  become  friable 
and  may  be  easily  ruptured.  Abscesses  and  hemorrhages  sometimes 
occur  in  the  substance  of  the  muscles. 

Bone-lesions  are  exceedingly  common  and  troublesome  sequelae.  Of 
Keen's  237  collected  cases,  periostitis  occurred  in  no,  necrosis  in  85, 
caries  in  13,  osteitis  (bone  abscess)  in  12,  osteomyelitis  in  10.  The 
tibia  was  affected  in  91  cases,  the  ribs  in  40.  In  51  cases  examined, 
pyogenic  cocci  were  found  in  13  and  typhoid  bacilli  in  38.  The  disease 
is  generally  chronic  and  liable  to  recur..  It  is  favored  by  traumatism 
received  shortly  before  or  after  the  fever.  Witzell  thinks  that  injury 
on  the  side  of  the  bath-tub  may  cause  it.  Keen  believes  that  muscular 
strain  is  sufficient,  and  that  this  fact  accounts  for  the  comparative  fre- 


68  PRACTICE  OF  MEDICINE 

quency  of  periostitis  of  the  crest  of  the  ihum,  the  anterior  superior 
spinous  process,  and  promontory  of  the  ischium,  where  independent 
affections  are  rare. 

Arthritis. — Keen  recognized  rheumatic,  septic,  and  typhoid  forms  of 
this  comparatively  rare  comphcation  in  84  collected  cases.  Spontaneous 
dislocation,  especially  of  the  hip,  is  liable  to  occur. 

Associated  Acute  fnfect/ons.— Malaria,  sometimes  occurs  in  conjunc- 
tion with  typhoid  fever,  giving  rise  to  the  double  infection,  typhomalarial 
fever.  This  is  not  a  distinct,  hybrid  disease,  as  was  at  one  time  believed. 
Some  cases  of  typhoid  fever  show  more  or  less  distinctly  remittent  or 
intermittent  features,  even  when  the  plasmodium  is  absent.  Measles, 
smallpox,  chicken-pox,  scarlet  fever,  diphtheria,  whooping-cough,  and 
noma  sometimes  develop  during  the  course  of  the  fever.  Erysipelas 
has  rarely  been  observed.  Typhus  fever  has  been  encountered  in  asso- 
ciation with  typhoid,  in  a  few  instances.  Miliary  tuberculosis  is  some- 
times associated  with  it.  It  is  an  interesting  fact  that  choreic  move- 
ments and  epileptic  seizures  generally  cease  during  typhoid  fever,  and 
that  sugar  may  for  a  time  disappear  from  the  urine  of  the  diabetic 
patient. 

Septic  infection  may  happen  during  the  later  weeks  of  the  disease 
or  as  late  as  two  weeks  after  the  fall  of  the  temperature.  It  may  take 
the  form  of  septicemia,  indicated  by  chilliness  with  moderate  fever,  sweat- 
ing, and  weakness ;  or  the  infection  may  be  pyemic  in  character,  usually 
manifested  by  frequent  chills,  high  but  irregular  temperature,  and  the 
development  of  thromboses,  abscesses  or  boils  about  the  buttocks, 
axillae,  or  joints.    Abscess  of  the  breast  has  been  observed. 

Re/apses. — A  relapse  is  due  to  reinfection.  It  usually  occurs  after 
complete  defervescence,  sometimes  several  weeks  after  the  temperature 
has  been  normal.  It  may  occur,  however,  before  complete  defervescence. 
Of  the  cause  we  know  comparatively  little.  It  has  been  suggested  that 
the  reinfection  is  due  to  the  inoculation  of  healthy  intestinal  follicles  by 
the  sloughs  cast  off  from  the  original  ulcers;  but  in  some  instances  the 
more  recent  lesions  are  found  higher  up  in  the  bowel  than  those  of  the 
original  infection.  As  Chiari  suggests,  the  reinfection  no  doubt  often 
arises  from  the  escape  of  bacilli  from  the  gall-bladder.  From  one  to  five 
relap^ses  have  been  observed  in  the  same  patient. 

The  onset  of  a  relapse  is  sometimes  abrupt,  often  with  a  chill,  and 
the  temperature  may  rise  suddenly,  but  in  most  cases  it  shows  the  t3^pical 
daily  ascent.  There  is  no  prodromal  stage.  All  the  symptoms  return, 
including  the  rash  and  splenic  enlargement.  The  eruption  may  appea-r 
as  early  as  the  third  or  fifth  day.  The  course  of  the  disease  is  not 
usually  so  long  or  so  severe  as  in  the  original  attack,  but  in  some  in- 
stances, especially  when  the  original  attack  was  mild,  it  has  been  much 
more  protracted  and  even  fatal.  Its  course  is  often  more  severe  than 
that  of  the  original  disease,  especially  when  it  develops  early.  The 
differential  diagnosis  of  a  relapse  is  often  difficult. 

Recrudescence  is  simply  a  return  of  the  fever  without  aggravation 
of  the  other  symptoms  after  the  temperature  has  been  normal  for  a  few 
days.  Its  cause  cannot  always  be  determined,  but  in  some  cases  it  is  due 
to  too  free  nourishment,  nervous  excitement;  occasionally,  perhaps,  to 
malaria. 


TYPHOID  FEVER  69 

Diagnosis. — General. — The  fact  that  typhoid  fever  is  the  most  fre- 
quent of  the  continued  fevers  warrants  its  consideration  in  every  case 
of  protracted  elevation  of  temperature.  When  a  person  between  1 5  and 
30  years  of  age  has  a  shght  fever,  with  a  rapid,  soft  pulse,  a  furred  and 
slightly  tremulous  tongue,  and  gives  a  history  of  lassitude,  headache, 
pains  in  the  back  and  limbs,  anorexia,  chilly  sensations,  restless  sleep, 
gradually  becoming  more  pronounced  for  a  week  or  two,  typhoid  fever  is 
highly  probable.  The  diagnosis  should  rarely  be  made,  however,  at  the 
first  examination.  If  nose-bleed,  constipation,  or  diarrhea  is  added  to 
the  symptoms,  and  a  cathartic  has  been  found  unusually  brisk  in  its 
action,  a  tentative  diagnosis  may  be  made,  particularly  if  the  disease 
is  prevalent  in  the  vicinity  at  the  time  or  a  probable  source  of  infection 
can  be  traced.  If,  after  a  few  days'  observation  of  the  case,  it  is  found 
that  the  temperature  has  followed  the  regular  course  of  elevation; 
that  the  pulse  has  become  more  compressible,  rapid,  and  dicrotic,  the 
tongue  more  heavily  coated  and  red  at  the  tip  and  edges,  the  abdomen 
distended  and  tympanitic,  with  tenderness  and  slight  gurgling  in  the 
ileo-cecal  region,  and  enlargement  of  the  spleen — then  the  diagnosis  is 
all  but  positive.  Add  to  these  symptoms,  after  seven  or  eight  days  of 
fever,  the  characteristic  rash,  and  the  diagnosis  becomes  positive.  Un- 
fortuna,tely  such  cases  are  the  exception  rather  than  the  rule.  Some 
symptoms  are  usually  wanting,  and  in  some  cases  the  patient  is  not 
seen  until  the  condition  of  hebetude  obscures  the  history  and  subjective 
symptoms.  In  the  absence  of  the  eruption  in  such  cases  the  diagnosis 
becomes  exceedingly  difficulty,  and  often  impossible,  for  a  time  at  least. 
Rarely  the  diagnosis  is  revealed  by  such  an  accident  as  a  profuse  in- 
testinal hemorrhage,  or  possibly  only  by  the  discovery  of  pathogno- 
monic lesions  after  death.  In  many  instances,  particularly  in  the  rural 
districts,  small  towns,  or  summer  resorts,  it  is  possible  to  clear  up  an 
obscure  case  by  tracing  the  infection  to  a  previous  case  of  the  disease. 
To  more  effectually  establish  the  diagnosis,  several  tests  may  be  made. 

Specific  Diagnosis. — Bacteriological  Test — The  bacilli  may  be  found, 
by  plate  culture,  in  the  urine  and  feces  of  most  cases  at  a  variable  period 
from  the  beginning  of  the  first  week  to  the  end  of  the  second  and  there- 
after. (For  method,  see  p.  747.)  They  may  be  found  also  in  the  blood 
obtained  by  puncture  of  the  rose-spots ;  puncture  of  the  spleen  is  rarely 
justifiable. 

Diazo   Test. — For   Ehrlich's  diazo  reaction,   see  p.    734. 

Blood  Test. — The  most  valuable  feature  of  the  blood-count  is  the 
absence  of  leucocytosis  at  all  stages  of  the  disease.  Anemia  is  also 
absent  until  the  decline  of  the  temperature. 

Serii7n  Test. — Widal's  serum  test  is  described  on  page   717. 

Differential  Diagnosis. — The  chief  obstacle  to  diagnosis  is  the  great 
diversity  of  manifestations  in  different  cases,  many  of  which  assume  a 
resemblance  to  other  diseases.  The  most  distinctive  features  are :  the 
peculiar  temperature  curve,  the  eruption,  the  absence  of  leucocytosis,  and 
the  reactions  to  the  diazo  and  Widal  tests.  The  following  summary 
will  assist  in  its  differentiation  from  the  diseases  which  it  most  frequently 
resembles  : 

Malaria. — Typhoid  fever  may  assume  an  intermittent  course,  to  the 
extent  that  the  fever  is  higher  on  every  second  or  third  day,  and  chilly 


7©  PJL4CTICE  OF  MEDICINE 

sensations  may  be  felt ;  but  the  periodical  chills,  profuse  sweats,  and  com- 
plete intermission  of  temperature  are  rarely  seen.  Quinin  has  little 
effect  on  the  temperature.  It  may  resemble  intermittent  fever,  especially 
in  children,  in  whom  the  eruption  does  not  always  appear.  The  estivo- 
autumnal  type  of  malaria  is  excluded  with  most  difficulty,  however, 
especially  in  malarious  districts.  In  it  there  is  often  a  history  of  malaise 
preceding  the  fever,  the  chill  may  be  absent,  vomiting  and  diarrhea 
are  often  present,  the  temperature  range  may  be  almost  uniform,  the 
cheeks  are  flushed,  the  tongue  dry  and  coated,  possibly  with  a  yellowish 
or  brownish  fur,  and  the  spleen  is  enlarged.  But  the  rash  does  not 
appear,  the  serum  test  is  negative,  and  the  plasmodium  or  an  abundance 
•of  pigment  is  found  in  the  blood. 

Cerebrospinal  Meningitis. — Cases  that  show  unusual  irritation  of 
the  meninges  bear  a  strong  resemblance  to  this  disease,  but  meningitis 
is  a  much  less  frequent  disease.  The  nervous  disturbances,  rigidity  of 
the  neck  or  opisthotonos,  convulsions,  photophobia,  and  strabismus 
are  usually  more  pronounced  than  in  any  case  of  typhoid  fever.  The 
cutaneous  and  tendon  reflexes  are  very  irregular  in  their  responses,  the 
rose-spots  are  absent,  and  the  abdominal  symptoms  are  less  pronounced 
or  absent.  For  a  few  days,  howeverj  a  diagnosis  may  not  be  possible 
in  some  cases. 

Lobar  Pneumonia. — When  a  double  infection  occurs  and  both  diseases 
are  present,  the  greater  prominence  of  the  initial  symptoms  of  pneu- 
monia, as  compared  to  those  of  typhoid  fever,  may  prevent  the  early 
recognition  of  the  latter  disease.  Again,  typhoid  sometimes  begins  with 
intense  pleuritic  pain  which  leads  to  a  suspicion  of  pneumonia.  In  the 
absence  of  double  infection,  however,  there  is  little  cause  for  confusion, 
since  there  is  less  cough,  no  dullness  on  percussion,  the  rales  are  mostly 
sibilant  and  not  confined  to  one  region,  no  rusty  sputum,  and  a  dif- 
ferent temperature  curve.  The  blood-count  and  serum  test  assist  in  the 
diagnosis. 

Septicemia. — When  the  location  of  the  suppuration  has  not  been  recog- 
nized, this  condition  may  resemble  typhoid  fever,  but  the  temperature 
is  not  so  uniform;  leucocytosis  is  present  and  careful  search  will  gener- 
ally reveal  suppuration.  In  pyemia,  severe  chills  are  generally  present, 
and  the  temperature  range  is  wide,  with  decided  hyperpyrexia  in  many 
cases.    The  Widal  test  fails. 

Uremia.— K  uremic  condition  may  obscure  the  diagnosis  in  the  begin- 
ning of  some  cases,  rarely  at  any  other  time.  But  the  tense  pulse, 
rapid  respiration,  contracted  pupils,  and  absence  of  abdominal  symptoms 
would  serve  to  distinguish  the  condition.  Uremia  may,  however,  occur 
as  a  complication,  and  prolonged  uremic  coma  sometimes  resembles 
typhoid  fever  so  closely  as  to  be  differentiated  only  by  careful  analysis 
of  the  urine. 

Acute  Miliary  Tuberculosis.— \rv  many  cases  there  is  a  history  of 
previous  tubercular  disease;  the  pulse  and  respiration  are  rapid,  the 
mind  is  usually  clear,  the  cough  is  more  annoying,  the  sputum  is  often 
bloody,  the  abdominal  symptoms  are  not  so  well  marked,  tubercle 
bacilli  may  be  found  in  the  blood  or  sputum,  leucocytosis  and  anemia 
are  present,  and  tubercles  may  be  discovered  in  the  choroid  on  ophthal- 
moscopic examination. 


TYPHOID  FEVER 


71 


Tubercular  meningitis  usually  occurs  in  children;  there  is  a  history 
of  irritability  preceding  the  stupor,  constipation  is  persistent,  the  ab- 
domen is  usually  flat,  leucocytosis  is  present,  and  tubercles  may  be  found 
in  the  choroid. 

In  tubercular  peritonitis,  the  temperature  is  irregular,  sometimes  sub- 
normal, the  abdominal  tenderness  greater  and  more  general;  ascites 
may  be  present,  and  the  leucocytosis  excludes  typhoid  fever. 

Appendicitis  is  usually  more  sudden  in  development,  with  greater  pain 
and  ileo-cecal  tenderness;  or,  if  of  slow  development,  the  constitutional 
symptoms  are  less  prominent.  Vomiting  is  often  present.  Percussion 
of  the  region  elicits  tympanitic  dullness,  as  distinguished  from  the  res- 
onance of  distention,  and  tumefaction  may  be  felt.  Tenderness  at 
McBurney's  point  and,  more  particularly,  leucocytosis  and  the  failure 
of  the  Widal  test  establish  the  diagnosis. 

Influenza  of  the  abdominal  type  is  sometimes  excluded  with  difficulty 
for  a  time  on  account  of  the  headache,  abdominal  tenderness,  pain,  and 
diarrhea.  But  the  onset  is  generally  more  sudden,  the  prostration 
earlier  developed;  the  symptoms  more  numerous  and  painful.  The 
tongue  in  influenza  is  bright  red  with  prominent  papillse. 

Malignant  endocarditis  sometimes  resembles  typhoid  fever,  but  is  an 
infrequent  disease.  Abdominal  tenderness,  diarrhea,  splenic  enlargement, 
and  stupor  are  sometimes  present.  There  is  generally,  although  not 
always,  great  cardiac  pain  and  distress.  The  onset  is  sudden,  the  tem- 
perature irregular,  and  leucocytosis  is  present. 

Relapsing  fever  is  very  infrequent  in  America.  The  invasion  is  sudden, 
with  a  chill;  the  pain  is  epigastric  in  location;  there  is  no  rose-eruption; 
the  nervous  phenomena  are  less  pronounced  and  the  spirilla  are  readily 
found  in  the  blood. 

Typhus  fever  is  seldom  encountered  except  in  epidemics  confined  to 
a  single  institution  or  ship.  The  onset  is  sudden,  the  stupor  profound, 
the  face  is  dusky,  the  eyelids  swollen,  the  pupils  contracted;  there  is 
a  macular  eruption  usually  appearing  on  the  fourth  or  fifth  dav, 
changing  into  petechias;  the  duration  of  the  disease  is  short  and  its 
termination  is  by  crisis. 

The  Para-  Infections. — There  remains  a  not  well  defined  group  of  dis- 
eases, clinically  almost  identical  with  typhoid  fever,  but  due  to  infection 
by  the  so-called  paratyphoid  or  paracolon  bacilli.  In  many  instances 
a  differentiation  can  be  made  only  by  the  bacteriological  or  serum  tests. 
The  Widal  reaction  is  almost  always  absent. 

Ptomainpoisoning  and  autointoxication  with  leucomains  are  generally 
to  be  excluded  by  the  abruptness  of  onset,  often  with  vomiting,  diarrhea, 
and  prostration,  and  by  the  absence  of  serum  reaction. 

Prognoses. — An  unconditionally  favorable  prognosis  should  never  be 
made  in  this  disease,  for  the  most  distressing  complications  often  arise 
in  the  mildest  and  most  hopeful  cases;  and  in  the  absence  of  compli- 
cations a  sudden,  even  fatal,  collapse  may  occur.  The  mortality  in  pri- 
vate practice  is  usually  from  5  to  10  per  cent,  and  in  hospital  practice 
from  7  to  15  per  cent.  The  death-rate  has  been  reduced  about  one- 
half  since  the  introduction  of  the  cold-bath  treatment.  Some  epidemics 
are  characterized  by  a  low  mortality,  others  by  an  excessively  high  rate. 
Regional  difl'erences  may  also  be  o'bserved  in  some  instances.     The  mor- 


72 


PRACTICE  OF  MEDICINE 


tality  in  women  is  higher  than  in  men  and  in  fat  persons  than  in  lean. 
From  puterty  on,  the  disease  becomes  more  fatal  with  the  advance  of 
years,  yet  old  people  often  make  excellent  recoveries.  The  disease  is 
usually  mild  in  children.  An  impoverished  state  of  nutrition,  partic- 
ularly that  due  to  chronic  alcoholism,  diminishes  the  chance  of  recovery. 
The  severity  of  the  type  of  infection  has  a  great  influence  on  the  mor- 
tality and  probably  accounts  for  the  difference  in  different  epidemics. 
The  extent  to  which  the  nervous  system  is  involved  and  the  degree  of 
pyrexia  are  important  factors.  Hyperpyrexia  is  indicative  of  danger 
only  when  it  is  continuous  for  a  number  of  days  with  but  slight  remis- 
sions. No  definite  degree  of  fever  is  necessarily  fatal,  but  recovery  sel- 
dom occurs  after  the  temperature  has  reached  io6°  F.  (41.1°  C.)  four 
or  five  days  in  succession;  the  danger  lies  in  the  profound  intoxication 
of  the  nervous  system  revealed  by  the  high  temperature.  Delirium  is 
an  unfavorable  symptom,  especially  when  it  develops  early  and  assumes 
the  low  muttering  form.  Excessive  meteorism  and  hemorrhage  are  also 
dangerous  symptoms,  but  not  necessarily  fatal.  The  prognosis  is  espe- 
cially bad  in  the  ambulatory  form  of  the  disease,  owing  to  the  greater 
frequency  of  complications.  Sudden  death  sometimes  occurs  without 
premonitory  symptoms  and  without  discoverable  cause  even  after  con- 
valescence has  been  well  established.  It  is  probably  due  in  most  cases 
to  a  failure  on  the  part  of  the  weakened  heart,  a  "delirium  cordis." 
But,  on  the  other  hand,  it  should  be  remembered  that  recovery  often 
occurs  in  the  most  hopeless  cases,  and  a  positively  unfavorable  prognosis 
should  not  be  too  soon  pronounced. 

Treatment.— Prophylaxis.— T\\^  measures  to  be  adopted  for  the  pre- 
vention of  typhoid  fever  are  in  part  municipal  and  in  part  personal. 
It  is  the  duty  of  physicians  to  enhghten  the  people  in  the  possibility 
of  preventing  the  disease,  and  the  measures  to  be  adopted.  The  impor- 
tance of  a  pure  water-supply,  free  from  possible  contamination,  and  the 
necessity  of  a  proper  system  of  sewers  should  be  promulgated.  Dairy- 
men should  be  taught  the  importance  of  using  only  boihng  water  for 
the  cleansing  of  cans  and  utensils. 

Individual  protection  theoretically  requires  the  abstaining  from  every- 
thing that  has  not  been  disinfected  by  heat.  Drinking-water  ard  mil'k 
must  be  thoroughly  boiled  and  cooled  in  bottles,  for  the  addition  of 
ice  is  not  safe.  All  utensils  must  be  cleansed  in  water  that  has  been 
boiled.  Green  vegetables,  to  be  eaten  raw,  must  be  thoroughly  washed 
in  sterihzed  water  or  refrained  from.  Oysters  fed  in  the  mouths  of 
streams  contaminated  with  sewage  must  not  be  eaten  raw.  In  times 
of  danger,  these  requirements  are  imperative,  and  there  are  few  cities 
in  which  the  requirements  in  regard  to  water  must  not  be  carried  out 
at  all  times.  In  villages  and  in  the  country,  however,  the  purity  of  the 
water  is  often  a  matter  of  certainty,  and  boiling  may  be  neglected. 
Filtration  has  done  much  to  reduce  the  prevalence  of  the  disease  in 
some  places,  notably  in  London,  but  it  is  absolutely  untrustworthy 
for  the  purification  of  contaminated  water,  since  the  bacilli  are  capable 
of  passing  through  many  of  the  house  filters.  Visitors  and  recent  resi- 
dents should  be  particularly  careful  to  obtain  their  food  and  drink  from 
uncontaminated  sources,  or  to  thoroughly  disinfect  them. 

Z?m>//^r/w?/.— Methods  of  antisepsis  must  be  applied  to  the  patient,  to 


TYPHOID  FEVER 


73 


his  excreta,  to  the  bed-linen,  and  more  or  less  generally  to  all  articles, 
coming  in  contact  with  the  patient.  The  best  disinfectants  for  feces 
and  urine  are:  a  i  ;5oo  acidulated  solution  of  mercuric  chlorid,  a  i  :20 
solution  of  commercial  carbolic  acid,  and  fresh  chlorinated  lime.  Re- 
cently a  I  :2o  solution  of  formaldehyd  has  been  much  employed.  For 
solutions  and  methods,  see  p.  727. 

Preventive  inoculation  has  been  practiced  with  apparently  some  de- 
gree of  success.  In  Maidstone,  95  persons  escaped  infection  after  inocu- 
lation. In  the  recent  Boer  war,  200  English  troops  were  inoculated, 
of  whom  3,  or  1.5  per  cent.,  took  the  disease;  none  died.  The 
inoculation  produces  local  reaction,  a  rise  of  temperature  and  the 
serum  of  the  person  acquires  agglutinative  properties,  reacting  to  the 
VVidal  test.  The  results  are  not  conclusive,  but  justify  a  hope  for  future 
success. 

General  Management. — Good  nursing  is  more  important  than  drugs. 
The  patient  should  be  put  to  bed  immediately  when  the  disease  is 
suspected,  and  kept  there  until  convalescence  is  fully  established.  This 
is  usuaHy  from  ten  days  to  two  weeks  after  the  temperature  has  ceased 
to  rise  above  the  normal.  The  sick-room  should  be  large  and  airy, 
if  possible  on  the  sunny  side  of  the  house.  An  abundance  of  fresh  air 
should  be  admitted  without  too  much  draft.  The  temperature  of  the 
room  should  be  68°  F.  (20°  C.)  in  daytime  and  65°  F.  (18''  C.)  at 
night.  Perfect  quiet  must  be  maintained.  The  attendants  should 
be  limited  to  a  nurse  and  one  member  of  the  family ;  visitors  should  be 
excluded.  Unnecessary  talking,  but,  above  all  things,  whispering,  must 
be  prohibited.  The  bed  should  be  narrow  and  low  enough  to  permit 
easy  handling  of  the  patient.  A  woven-wire  spring,  with  a  soft  hair 
mattress  covered  with  a  double  blanket,  affords  the  greatest  comfort. 
A  rubber  cloth  should  be  placed  under  the  sheet.  The  bed  must  be 
kept  clean  and  smooth  at  all  times  to  prevent  bedsores,  and  an  air- 
cushion  should  be  used  if  their  formation  is  threatened.  The  head 
should  not  be  too  high. 

A  competent  nurse  should  be  employed  when  circumstances  permit. 
The  physician  should  write  out  daily  his  instructions  as  to  diet,  nursing, 
disinfection,  and  medication,  and  in  return  should  receive  from  the  nurse 
a  daily  record  of  the  temperature,  taken  every  three  hours,  with  a  re- 
port of  the  number  of  dejections,  baths,  h6urs  of  sleep,  amount  of 
nourishment  and  drink  administered,  and  any  unusual  symptoms — in 
short,  a  history  of  the  case  for  the  last  24  hours.  The  temperature 
chart  should  be  kept  from  the  patient's  view.  He  should  not  be  informed 
of  any  unfavorable  symptoms  or  complications;  he  need  not  be  made 
aware  of  intestinal  hemorrhages.  He  should  not  be  permitted  to  lie 
constantly  on  the  back,  but  should  be  carefully  turned  upon  either 
side  from  time  to  time.  He  must  never  be  allowed  to  rise  for  any  pur- 
pose. It  is  better  to  have  him  naked  in  bed,  for  a  gown  becomes  wrin- 
kled and  rough.  Food  and  drink  must  be  given  through  a  tube. 
The  bedpan  must  always  be  used.  The  patient  generally  finds  difficulty 
at  first  in  its  use,  but  rarely  fails  to  become  accustomed  to  it  in  a  few 
days.  It  is  only  in  the  rarest  cases,  when  the  nervous  excitement  occa- 
sioned by  unsuccessful  attempts  to  use  the  bedpan  is  a  positive  menace 
to  the  patient,  that  the  physician  should  consent  to  his  being  carefully 


74  PRACTICE  OF  MEDICINE 

lifted  upon  a  commode.  The  patient  must  not  be  allowed  to  make  the 
slightest  exertion. 

The  mouth,  tongue,  and  lips  should  be  cleansed  once  or  twice  daily. 
A  solution  of  borax,  or  equal  parts  of  hydrogen  peroxid  and  glycerin, 
or  listerin,  on  a  soft  rag  may  be  employed.  It  may  be  necessary  to 
scrape  the  tongue.  The  system  requires  an  abundance  of  water  for  the 
maintenance  of  the  secretions,  especially  that  of  the  kidneys,  which  are 
burdened  with  the  elimination  of  the  toxic  matters.  At  least  a  quart  a 
day  of  pure  cold  water  should  be  given  with  the  regularity  of  medicine, 
for  the  patient  seldom  asks  for  it.  This  is  one  of  the  most  important 
items  in  the  treatment.  The  addition  of  a  few  drops  of  dilute  hydro- 
chloric or  phosphoric  acid  or  a  little  lemon-juice  is  beneficial  and  gener- 
ally agreeable.  The  aromatic  sulphuric  acid  may  be  substituted  when 
the  diarrhea  is  excessive  or  the  sweating  profuse. 

Hydrothe7'apy. — The  Brand  method,  or  cold-bath  treatment,  is  the 
most  esteemed  of  the  methods  of  hydrotherapy.  The  benefits  obtained 
from  it  are:  (i)  The  reduction  of  temperature.  This  is,  however,  one 
of  the  minor  considerations.  (2)  The  stimulating  effect  upon  the  ner- 
vous system.  There  is  no  other  method  that  will  so  promptly  and  so 
eftectually  clear  the  intellect  and  arrest  the  tremor.  After  the  bath  the 
patient  generally  falls  into  a  tranquil  sleep  of  several  hours'  duration. 
(3}  Stimulation  of  the  heart's  action.  The  danger  of  sudden  failure 
of  the  circulation  is  removed;  the  pulmonary  circulation  is  rendered 
stronger,  and  thus  the  tendency  to  hypostatic  congestion  and  throm- 
bosis is  diminished.  The  increased  renal  circulation  results  in  a  more 
abundant  elimination  of  the  toxic  matter.  (4)  An  increase  of  respira- 
tory movements,  especially  deep  respiration,  through  which  the  tendency 
to  bronchitis  is  lessened. 

The  full  Brand  method  is  contraindicated  :  (i)  WTien  pneumonia  or 
pleurisy  is  present;  (2)  when  alarming  paroxysms  of  dyspnea,  cough- 
ing, or  cyanosis  are  induced  by  the  bath;  (3)  after  perforation  or 
peritonitis  has  developed;  (4)  when  there  are  extensive  bedsores  which 
would  be  injured  by  the  cold  water.  A  modified  bath  must  sometimes 
be  administered  to  very  elderly  persons  and  those  who  cannot  become 
accustomed  to  the  full  bath.  As  in  all  therapeutic  methods,  however, 
it  is,  as  a  rule,  better  to  omit  the  treatment  altogether  than  to  give  it 
in  a  half-way  or  careless  manner.  The  first  sensation  of  a  dip  into  cold 
water  when  the  temperature  of  the  body  is  abnormally  high  is  by  no 
means  pleasant,  but  there  are  few  persons  who  will  persistently  object 
to  it  after  they  have  experienced  the  after-eff"ects  and  have  been  made 
to  understand  the  benefits  they  will  derive  from  the  treatment. 

The  Brand  treatment  should  be  begun  early,  always  before  the  fifth 
day  if  possible.  The  baths  should  be  repeated  ever}^  three  hours  as 
long  as  the  rectal  temperature  exceeds  103°  F.  (39°  C.)  or  as  long  as 
the  sensorium  continues  depressed,  even  \\dth  a  lower  temperature. 

The  Method.—.^  portable  bath-tub  of  sufficient  length  and  width  to 
accommodate  the  patient  should  stand  in  readiness  at  his  bedside, 
protected  from  his  view  by  a  screen.  It  should  be  filled  to  three- 
fourths  of  its  depth  with  water  of  90°  F.  (32°  C.)  for  the  first 
bath.  The  temperature  of  the  water  should  be  reduced  5°  F.  (2.5°  C.) 
at  each   successive  bath  until  it  has  reached  65°  F.  (18.5°  C.)  and  no 


TYPHOID  FEVER  75 

lower.  The  patien-t  is  given  a  stimulant,  brandy  or  black  coffee;  he  is 
then  uncovered,  a  napkin  placed  over  the  genitals,  and  the  face  bathed 
with  cold  water.  He  is  now  transferred  to  the  bath  by  two  attendants, 
one  grasping  him  under  the  shoulders,  the  other  just  below  the  knees. 
This  should  be  done  as  gently  as  possible.  Brisk  friction  is  performed 
during  the  bath.  Every  part  of  the  body  except  the  lower  abdomen 
should  be  gently  but  firmly  rubbed  in  order  to  prevent  chilliness  and 
to  stimulate  the  cutaneous  reaction.  Nothing  short  of  chattering  teeth 
or  a  cyanotic  appearance  of  the  face  should  be  regarded  as  an  indication 
to  discontinue  the  bath  in  less  than  twenty  minutes.  While  the  patient 
is  in  the  water,  the  bed  should  be  prepared  for  his  return.  This  is  done 
by  laying  over  it  a  double  blanket,  and  over  this  a  sheet.  He  is  laid 
upon  this  and  the  sheet  is  folded  over  him,  a  fold  being  passed  between 
the  arms  and  sides  and  between  the  legs,  and  the  blanket  is  wrapped 
around  this.  Here  he  is  permitted  to  lie  undisturbed  for  five  or  ten 
minutes.  If,  however,  the  temperature  was  but  moderate  before  the  bath 
he  may  be  dried  at  once,  first  with  the  sheet,  and  afterward  with  soft 
towels.  Hot  bottles  should  be  placed  at  his  feet.  Reaction  is  generally 
prompt.  Prolonged  shivering  after  the  bath,  Baruch  tells  us,  points 
to  some  defect,  either  in  duration  or  temperature,  or  the  friction  may 
not  have  been  properly  performed. 

It  is  often  a  difficult  question  to  determine  whether  the  cold-bath 
treatment  should  be  administered  to  a  patient  first  seen  in  the  second 
or  third  week  of  the  disease.  It  must  be  left  to  the  judgment  of  the 
physician,  based  upon  the  condition  of  the  patient.  A  young  physician 
would  perhaps  better  select  a  mild  case  in  the  beginning  of  its  course 
for  his  first  application  of  the  treatment,  particularly  if  he  be  located  in 
a  community  where  the  method  has  not  been  practiced. 

A  great  many  intelligent  physicians  oppose  the  cold-bath  treatment 
upon  various  grounds,  others  employ  it  in  a  modified  form.  Probably 
the  best  modification,  especially  for  the  treatment  of  children,  the  aged, 
and  persons  who  persistently  refuse  to  become  accustomed  to  the  Brand 
bath,  is  found  in  the  use  of  water  at  90°  F.  (32°  C.)  at  the  beginning  of 
every  bath,  subsequently  reducing  the  temperature  of  it  by  the  gradual 
addition  of  ice-water  until  70°  F.  (21°  C.)  or  even  65°  F.  (18.5°  C.) 
is  reached  (Ziemmsen's  method).  As  substitutes  for  the  cold  bath, 
sponging  and  the  cold  pack  are  the  most  popular. 

The  cold  pack  is  applied  by  wrapping  the  patient  in  a  sheet  wrung 
out  of  water  at  60°  or  65°  F.  (15.5°— 18.5°  C.),and  then  sprinkhng  him 
with  water  of  the  same  temperature  from  a  watering-can.  It  does  not 
compare  favorably  in  its  results  with  either  the  cold  bath  or  sponging. 

Cold  sponging  should  be  practiced  in  all  cases  that  are  not  subjected 
to  the  cold-bath  method.  The  entire  body  is  sponged  with  likewarm, 
cold,  or  iced  water  for  15  or  20  minutes  at  a  time.  The  effect  of  the 
ice-cold  sponging  is  an  almost  as  pronounced  stimulation  of  the  nerve 
centers  as  is  obtained  from  the,  bath,  and  it  is  secured  with  much  less 
labor. 

Dietetic  Treatment. — Nourishment  must  be  administered  entirely  in 
fluid  form.  Milk  is  the  best  food.  Four  pints  should  be  given  to  an 
adult  in  twenty-four  hours,  which  is  about  equivalent  to  a  tumblerful 
every  two  hours  in  daytime  and  a  little  less  often  at  night.     It  may 


76  PRACTICE  OF  MEDICINE 

be  given  cold  or  warm.  If  objectionable  to  the  patient,  its  taste 
may  be  modified  by  the  addition  of  a  little  salt,  Vichy,  carbonated 
water,  a  little  coffee,  tea,  or  cocoa.  In  some  persons  it  produces 
constipation,  flatulence,  tympanites,  or  diarrhea,  with  undigested  curd 
or  fat  in  the  stools.  In  such  cases,  if  the  addition  of  lime-water  or 
Vichy  does  not  relieve  the  difficulty,  the  milk  may  be  partially  pre- 
digested,  or  the  quantity  must  be  reduced  and  other  nourishment  given. 
Beef,  mutton,  or  chicken  broth  and  bouillon  answer  this  purpose. 
A  little  thoroughly  cooked  rice  or  the  white  of  an  egg  may  be  added 
to  the  broths.  If,  however,  the  diarrhea  be  severe,  broths  and  beef- 
juice  must  be  omitted  on  account  of  their  tendency  to  increase  it.  The 
whites  of  five  or  six  eggs  may  be  given  during  a  day,  beaten  with  milk 
or  sherry,  or  in  the  form  of  albumen-water,  flavored  with  lemon  or 
orange.  Panopepton  or  other  predigested  food  may  be  tried  with  cau- 
tion. But  it  should  be  borne  in  mind  that  every  unavoidable  departure 
from  a  strict  milk  diet  adds  risk  and  an  occasion  for  regret  in  case  of 
a  fatal  issue. 

-Dief  of  Convalescence. — It  is  a  safe  rule  not  to  allow  solid  food  for 
eight  or  ten  days  after  the  fever  has  remained  normal,  and  to  exercise 
especial  caution  in  the  addition  of  meat  to  the  dietary.  After  a  few 
days  of  normal  temperature,  a  soft  egg,  milk  toast,  custard,  and  junket 
may  be  added,  one  at  a  time  and  at  only  one  meal  each  day.  Then 
blanc-mange,  bread  and  milk,  boiled  rice,  bread  pudding,  and  other 
articles  made  of  eggs  and  milk  may  be  given  in  small  quantity,  the 
eff'ect  of  each  article  added  being  carefully  watched.  If  elevation  of 
temperature,  diarrhea,  or  other  disturbance  be  produced,  the  milk  diet 
must  be  resumed  for  a  few  days. 

Medicinal  Treatment. — No  routine  course  of  medication  is  required. 
Symptomatic  indications  should  be  met,  but  these  are  generally  if^. 
In  some  localities,  the  administration  of  quinin  for  a  few  days  is  judi- 
cious, in  order  to  exclude  the  possible  presence  of  malaria.  Small  doses 
of  calomel,  gr.  i-io  (0.006),  may  be  given  for  a  few  da3^s,  for  its  anti- 
septic effect,  especially  if  constipation  exist.  Salol,  /?-naphthol,  creosot, 
guaiacol,  and  other  intestinal  antiseptics  are  in  favor  with  some  author- 
ities.   They  probably  have  little  eff'ect  upon  the  infection. 

Inoculation  Treatment. — Several  attempts  have  been  made  to  treat 
the  disease  with  sterilized  liquid  obtained  from  cultures  of  the  bacillus 
typhosus  or  the  bacillus  pyocyaneus;  with  blood-serum  obtained  from 
convalescent  patients,  or  with  the  serum  of  dogs  that  have  been  inocu- 
lated with  typhoid  cultures.  In  most  instances  the  only  apparent  result 
was  a  reduction  of  temperature;  that  the  course  of  the  disease  was 
modified  could  hardly  be  asserted.  The  recent  experiments  of  Richardson, 
in  which  normal  blood-serum  was  added  to  the  curative  serum,  seem 
to  promise  better  results. 

Treatment  of  Special  Symptoms. — Fever. — The  best  means  of  reducing 
the  temperature  when  the  cold-bath  treatment  is  not  employed  is  by 
repeated  sponging  with  ice-water.  Antipyretics  of  the  coal-tar  series, 
as  phenacetin  and  acetanilid,  should  be  carefully  used,  if  at  all.  A 
mixture  of  equal  parts  of  guaiacol  and  glyercin  or  guaiacol  carbonate 
may  be  applied  with  friction  to  the  outer  side  of  the  thigh.  Its  action 
should  be  watched,  however. 


TYPHOID  FEVER 


77 


Diarrhea. — Four  or  five  stools  a  day  cannot  be  regarded  as  harmful. 
If  moderately  excessive,  they  may  be  checked  by  the  administration  of 
bismuth,  grs.  x  to  xv  (0.65 — i.o),  Dover's  powder,  grs.  iij  to  v  (0.2 — 
0.35),  or  camphorated  tincture  of  opium  in  teaspoonful  doses  repeated 
every  three  hours.  If  the  diarrhea  be  profuse,  the  lead  and  opium  pill 
or  morphin,  gr.  ^/g  (0.008),  may  be  required.  If  the  stools  are  offensive, 
salol,  grs.  v  (0.35),  may  be  given  with  the  opiate.  The  cause  of  the 
diarrhea  should  be  sought  by  examination  of  the  stools,  especially  for 
undigested  milk. 

Constipation  is  best  overcome  by  enemata  of  soapsuds,  oil,  or  glycerin. 
Small  doses  of  calomel  may  be  employed  in  the  first  days  of  the  attack. 

Tympanites. — Turpentine  stupes  or  hot  fomentations  should  be  ap- 
plied. Ten  drops  of  turpentine  internally,  in  emulsion  or  on  a  lump 
of  sugar,  are  often  effective.  When  the  colon  is  greatly  distended,  the 
introduction  of  a  rectal  tube  often  gives  vent  to  the  gas. 

Delirium. — Such  causes  as  meteorism  or  deficient  action  of  the  kidneys 
should  be  looked  for.  Quiet  restraint  must  be  exercised.  The  bromids 
act  well  in  some  cases;  morphin  must  be  employed  in  others.  Hydro- 
therapy is  probably  the  most  certain  means  for  its  prevention. 

Mania  requires  the  most  careful  attention.  The  patient  should  not  be 
left  alone  for  an  instant.  Hyoscin  hydrobromate  in  i-ioo  grain  (0.0006) 
doses  may  be  given,  and,  this  failing,  morphin  in  full  doses  must  be 
resorted  to. 

Hemorrhage  of  the  Bowels. — Absolute  rest  and  quiet  must  be  secured. 
The  patient  should  be  kept  in  a  quiet  doze  for  several  days  by  the  ad- 
ministration of  lead  and  opium  pills,  laudanum,  or  morphin  in  sufficient 
doses.  The  foot  of  the  bed  should  be  raised  and  a  Leiter  coil  or  other 
cold  application  should  be  applied  to  the  ileo-cecal  region.  Alcoholic 
stimulants  should  not  be  given,  except  in  case  of  extreme  collapse. 
Even  in  this  condition,  strychnin  given  hypodermically  is  safer.  Trans- 
fusion of  0.7  per  cent  saline  solution  into  a  vein  or  the  subcutaneous 
tissue  may  assist  in  tiding  the  patient  over. 

Perforation. — Surgical  aid  should  be  at  once  called,  unless  the  con- 
dition of  the  patient  is  so  extreme  as  to  clearly  preclude  the  possibility 
of  an  operation.  In  the  mean  time  the  patient  should  be  kept  under 
morphin. 

Cardiac  Weahiess. — Strychnin  should  be  given  every  three  or  four  hours 
in  increasing  doses,  up  to  1-20  grain  (0.003)  if  necessary.  Whisky  or 
brandy  may  be  given  in  the  absence  of  contraindications,  from  a  table- 
spoonful  every  three  hours  to  an  ounce  every  hour  until  reaction  is 
obtained. 

Bedsores  can  be  generally  prevented  by  thorough  cleanliness  and  keep- 
ing the  bed  and  skin  dry.  The  prominences  should  be  bathed  twice  daily 
with  alcohol,  brandy,  or  spirits  of  camphor,  dried,  and  dusted  with  an  an- 
tiseptic flesh-powder  or  the  stearate  of  zinc. 

Treatment  of  Convalescence. — As  soon  as  the  patient  has  begun  to 
take  solid  food,  he  may  begin  to  sit  up  in  bed.  He  may  be  partially 
raised  on  pillows  for  fifteen  to  thirty  minutes  at  a  time.  This  should 
be  practiced  for  several  days,  gradually  lengthening  the  time,  before  an 
attempt  is  made  to  sit  in  a  chair.  As  strength  returns,  the  amount 
of  exercise  permitted  may  be  increased.    As  soon  as  the  patient  is  able, 


78  PILICTICE  OF  MEDICINE 

he  should  spend  much  of  his  time  in  the  open  air,  getting  as  much 
sunshine  as  he  can  bear.  A  trip  to  the  country,  or,  better,  to  the  moun- 
tains, is  a  pleasant  and  profitable  mode  of  recuperation.  He  should  be 
fully  instructed  before  departure,  however,  as  to  the  danger  of  over- 
exertion and,  more  particularly,  as  to  that  of  overeating. 

A  bitter  tonic  should  be  prescribed,  and  iron  or  arsenic  is  often 
required  for  the  anemia  of  convalescence.  The  elixir  of  iron,  quinin,  and 
strychnin  is  one  of  the  most  serviceable  preparations  at  this  time. 

TYPHUS   FEVER. 

HOSPITAL  FEVER,  TAIL  FEVER,  CAMP  FEVER,  SHIP  FEVER,  SPOTTED 

FEVER. 

Typhus  fever  is  endemic  in  England,  notably  in  London,  in  Ireland,  Scotland,,. 
Russia,  southern  Europe,  and  Mexico.  It  is  seldom  met  with  in  the  United  States.  Cases 
have,  however,  occurred  in  Boston,  New  York,  Philadelphia,  and  Baltimore,  for  the  most 
part  among  Irish  immigrants. 

Dafinition. — A  highly  contagious  acute  infectious  disease  having  a  sud- 
den onset  and  definite  course,  with  macular  eruption,  terminating  with 
crisis  in  about  fourteen  days. 

Etiology. — Overcrowding,  un cleanliness,  poor  food,  poverty,  and  intem- 
perance are  the  principal  predisposing  factors,  hence  the  comparative 
frequency  of  the  disease  in  jails  and  camps.  The  disease  occurs  at  all 
seasons,  but  especially  in  winter  and  spring,  probably  because  this  is  the 
s-eason  of  overcrowding  among  the  poor.  The  sexes  are  attacked  about 
equally  and  no  period  of  life  is  exempt.  A  majority  of  its  victims  are 
between  20  and  40,  and  those  between  10  and  30  are  about  equal  to 
those  between  30  and  50. 

The  specific  infectious  agent  is  not  known.  A  streptobacillus,  a  dip- 
lococcus,  and  a  peculiar  spirocheta  have  been  found  in  the  blood  or 
other  fluids  by  difterent  investigators.  It  is  one  of  the  most  contagious 
of  the  infectious  diseases;  in  some  epidemics  the  physicians  and  nurses 
have  been  almost  universally  attacked.  This  feature  is  much  less  fre- 
quently noted,  however,  in  cases  that  occur  in  private  residences,  where 
careful  attention  can  be  given  to  methods  of  prophylaxis,  including  the 
removal  of  all  unnecessary  furniture,  carpets,  and  draperies  from  the  room, 
and  to  the  disinfection  of  the  patient,  especially  his  mouth  and  nostrils. 
The  infection  is  beheved  to  be  transported  by  the  desquamated  epidermal 
scales,  by  the  sputum  of  the  patient,  and  by  fomites.  The  poison  may 
be  retained  in  articles  of  clothing  for  several  months. 

Morbid  Anatomy. — ^No  characteristic  lesions  are  found  in  any  of  the 
organs.  The  eruption  remains  upon  the  skin  after  death,  and  ecchymoses 
are  found  upon  dependent  surfaces.  The  blood  is  dark  and  abnormally 
fluid.  It  has  been  compared  to  a  mixture  of  serum  and  snuft".  The 
muscles  have  a  dark  red  color,  frequently  show  granular  degeneration, 
particularly  in  the  heart,  and  sometimes  extravasations  of  blood.  My- 
ocarditis is  often  found,  and  the  endocardium  may  be  reddened.  There 
are  no  constant  lesions  in  the  intestines,  but  the  lymph-follicles  are 
frequently  enlarged  without  ulceration.  The  liver  is  enlarged  and  soft, 
and  the  spleen  is  usually  large.  The  kidne3''S  are  hyperemic  and  may 
show  the  changes  of  nephritis.     The  bronchial  mucous  membrane  is  con- 


TYPHUS  FEVER  79 

gested  and  coated  with  mucus;  sometimes  lobular  pneumonia,  less  fre- 
quently lobar  pneumonia  or  pleuritis,  i-s  found.  Hypostatic  congestion 
of  the  lungs  is  quite  common.  The  discoverable  lesions  of  the  nervous 
system  are  confined  to  slight  congestion  of  the  cerebral  and  spinal 
meninges,  sometimes  with  effusion  of  serum  into  the  subarachnoid  spaces 
and  ventricles. 

Symptoms. — The  incubation  lasts  from  nine  to  twelve  days,  during 
the  last  two  or  three  of  which  there  is  a  feeling  of  languor  or  a  loss  of 
appetite,  and  headache.  The  invasion  is  usually  sudden,  with  a  distinct 
rigor  or  a  succession  of  chills  for  several  days.  Severe  headache,  pain 
in  the  loins  and  limbs,  with  profound  prostration,  early  confine  the 
patient  to  his  bed.  The  face  is  flushed,  the  eyes  expressionless,  the 
conjunctivEe  reddened,  the  pupils  contracted.  The  tongue  has  a  white 
fur,  soon  becomes  dry,  and  sordes  form  upon  the  teeth.  Nasal  catarrh 
and  bronchitis  are  generally  present.  Persistent  vomiting  may  be  a 
troublesome  symptom.  The  patient  complains  of  ringing  in  the  ears, 
of  black  spots  before  the  eyes,  and  the  nervous  manifestations  increase 
in  severity  until  delirium  supervenes. 

The  temperature  rapidly  rises,  often  reaching  104°  F.  (40°  C.)  on  the 
first  evening.  It  may  attain  its  maximum,  105°,  106°  F.  (40.5° — 41.0° 
C.)  or  even  higher,  on  the  second  or  third  day.  Its  course  is  almost 
uniform,  showing  but  slight  remissions.  The  pulse  is  rapid  and  full; 
less  frequently  dicrotic  than  in  typhoid  fever.  The  heart  sounds  become 
indistinct,  and  a  systolic  murmur  is  often  heard.  The  respiration  is 
moderate.  The  urine  shows  the  usual  febrile  changes — diminution  of 
quantity,  with  increase  of  solids,  especially  of  urea  and  coloring  matter, 
decrease  of  chlorids,  and  often  a  trace  of  albumin. 

The  eruption  appears  on  the  third  to  the  fifth  day,  first  on  the  ab- 
domen and  upper  part  of  the  chest,  then  on  the  extremities  and  face. 
It  has  the  form  of  distinct  dark  red  papules  under  the  cuticle,  which 
soon  become  hemorrhagic  and  petechial  in  character.  The  skin  between 
the  papules  is  often  reddened.  Herpes  is  rarely  present.  The  general 
integument  is  dry.  A  furfuraceous  desquamation  during  convalescence 
has  been  described.  In  mild  cases  the  eruption  occasionally  fades 
away  without  passing  into  the  petechial  state,  and  the  symptoms 
begin  to  abate  with  the  decline  of  the  fever,  about  the  seventh  day. 
Some  epidemics  have  been  characterized  by  the  great  number  of  mild 
cases,  and  others  by  the  remarkable  severity  of  all.  In  severe  cases  the 
temperature  remains  high,  delirium  develops  and  often  becomes  violent 
or  it  may  deepen  into  coma.  Coma-vigil  is  often  seen.  The  bronchitis 
may  pass  into  lobular  pneumonia,  hypostatic  congestion  becomes  marked, 
and  death  may  ensue  from  exhaustion.  If  the  case  is  to  terminate 
favorably,  a  crisis  occurs  usually  on  the  17th  day,  occasionally  a  little 
earlier  or  later.  The  temperature  sinks  almost  uniformly  to  the  normal 
within  24  to  48  hours,  and  all  the  symptoms  rapidly  abate.  The  crisis 
is  accompanied  with  profuse  sweating  or  free  micturition.  An  extreme 
elevation  of  temperature,  sometimes  reaching  109°  F.  (42.7°  C),  gen- 
erally precedes  a  fatal  termination  and  is  sometimes  observed  before  the 
crisis.     Relapses  are  extremely  rare. 

Complications. — The  complications  are  those  ordinarily  seen  in  a  se- 
vere febrile  disease.     In  some  epidemics  gangrene  of  the  toes,  fingers,  or 


So  PRACTICE  OF  MEDICINE 

noee,  and,  in  children,  noma,  have  been  observed.  The  sequelae  are  few. 
Sometimes  anemia  persists,  and  neuralgia  or  paralysis,  probably  due 
to  neuritis,  has  been  seen. 

Diagnosis. — Owing  to  the  resemblance  of  mild  cases  to  typhoid  fever 
the  diagnosis  may  for  a  time  be  difficult,  particularly  in  the  absence  of 
an  epidemic.  It  can  generally  be  determined  by  the  following  points  : 
(i)  The  onset  is  more  abrupt,  often  with  a  pronounced  rigor.  (2)  The 
nervous  manifestations  appear  earlier  and  are  usually  more  severe. 
(3)  The  eruption  comes  out  earlier,  is  more  abundant  and  of  a  petechial 
character,  a  type  rarely  seen  in  typhoid  fever.  (4)  The  headache  and 
pains  in  the  limbs  are  more  severe.  (5)  The  temperature  is  higher, 
more  uniform,  terminates  earlier  and  by  crisis. 

Prognosis. — This  is  determined  chiefly  by  the  character  of  the  attack, 
the  severity  of  the  epidemic,  and  the  general  condition  of  the  patient. 
The  mortality  is  as  low  as  6  or  7  per  cent  in  mild  cases,  but  may 
exceed  20  per  cent  in  others. 

Treatment — Owing  to  the  contagiousness  of  the  disease,  the  patient 
should  be  immediately  isolated,  and  the  most  rigid  antisepsis  should  be 
practiced.  The  general  indications  are  the  same  as  those  for  typhoid 
fever.  Hydrotherapy  affords  the  best  means  of  combating  the  fever  and 
the  depression  of  the  nervous  system.  In  addition  to  this,  the  treatment 
should  be  supportive  and  stimulating.  Alcohol  should  be  freely  given, 
with  an  abundance  of  milk  and  beef-juice,  and  the  heart's  action  should 
be  supported  with  strychnin.  Every  effort  must  be  made  to  maintain 
the  strength  of  the  patient  until  the  infection  has  expended  its  force. 

RELAPSING  FEVER. 

RECURRENT  FEVER,  RELAPSING  TYPHUS,  SEVEN-DAY  FEVER,  FAMINE 

FEVER. 

Relapsing  fever  has  prevailed  more  or  less  epidemically  in  various  parts  of  the 
Old  World  at  difierent  periods  during  the  last  two  hundred  years,  possibly  from  an- 
tiquity. It  was  brought  to  America  by  Irish  immigrants  in  1844,  but  has  not  been 
encountered  here  since  1869. 

Definition.— Aji  acute  infectious  disease  caused  by  the  spirillum  of  Ober- 
meier,  characterized  by  from  two  to  five  febrile  paroxysms,  each  lasting 
about  six  days  and  separated  by  a  febrile  interval  of  the  same  dura- 
tion. 

Etiology. — The  specific  cause  of  the  disease  is  a  spirocheta,  a  delicate 
filamentous  spirillum  about  3o,a  in  length,  or  five  times  the  diameter 
of  a  red  blood-corpuscle.  These  are  found  in  the  blood  during  the 
febrile  paroxysms  and  are  then  actively  motile.  Shortly  before  tke 
crisis  they  disappear  and  remain  absent  during  the  afebrile  period.  They 
have  not  been  detected  in  any  of  the  other  fluids  of  the  body,  but  are 
found  in  the  spleen  and  very  rarely  in  the  blood  after  death.  Inoculation 
with  the  blood  of  a  patient  produces  the  disease,  even  in  one  who  has 
previously  passed  through  an  attack.  The  blood-serum  of  a  person 
having  the  disease  contains,  at  certain  periods,  a  substance  which  is 
exceedingly  toxic  to  the  spirillum.  The  disease  is  contagious  to  a  slight- 
ly less  degree  than  typhus  fever.  In  some  epidemics,  however,  this  feature 
is  more  prominent  than  in  others. 


RELAPSING  FEVER  Si 

A  Russian  physician  has  recently  investigated  the  possible  trans- 
mission of  the  disease  by  insects,  and  found  numerous  spirilla  in  the 
bodies  of  bedbugs  that  had  feasted  upon  patients  with  relapsing  fever. 
From  this  it  is  inferred  that  the  disease  may  be  transmitted  by  the  bug 
to  other  individuals. 

Morbid  Anatomy.— There  axe  no  typical  lesions.  Ecchymoses  are  gen- 
erally found.  After  death  during  a  paroxysm,  the  spleen  is  large  and 
soft,  and  cloudy  swelling  may  be  found  in  the  parenchyma  of  various 
organs.    Infarcts  are  sometimes  seen  in  the  spleen  and  kidneys. 

Symptoms.— The  incubation  period  is  generally  from  five  to  eight 
days.  Prodromal  symptoms  are  generally  absent.  The  invasion  is 
abrupt,  usually  beginning  in  the  morning  with  one  or  more  chills;  the 
temperature  rapidly  rises  to  102°  or  104°  F.  (38.9^ — 40°  C.)  by  the 
first  evening,  with  headache,  violent  pains  in  the  limbs  and  back,  and 
extreme  prostration.  Vertigo,  nausea,  and  vomiting  are  sometimes 
present.  The  breath  is  fetid.  The  pulse  ranges  from  no  to  130.  The 
liver  and  spleen  rapidly  enlarge  and  become  sensitive  to  pressure.  Profuse 
sweating  is  usual.  There  is  no  eruption,  as  a  rule,  but  occasionally 
herpes,  petechise,  or  miliary  vesicles  are  observed.  The  prostration, 
restlessness,  and  fever  reach  their  greatest  severity  from  the  fourth  to 
the  sixth  day.  There  is  often  a  sense  of  oppression  in  the  right  hypo- 
chondrium,  and  great  dyspnea.  The  crisis  occurs  while  the  disease  is 
at  its  height,  usually  on  the  fifth  or  sixth  day,  rarely  as  early  as  the 
third  or  late  as  the  tenth  day.  A  profuse  sweat  comes  on  and  the 
temperature  drops  from  7°  to  10°  F.  during  a  single  night.  The  pulse 
becomes  slow  and  all  the  symptoms  subside.  Old  persons  often  sink 
into  collapse.  Convalescence  is  rapid,  but  recovery  becomes  more  delayed 
with  the  repetition  of  the  paroxysms.  In  some  instances  the  disease 
terminates  after  the  first  paroxysm.  A  fatal  termination  may  follow 
collapse  or  result  from  prostration  or  heart-weakness,  but  it  is  generally 
due  to  some  complication. 

Bilious  Typhoid. — A  special  form  of  the  disease,  in  which  pernicious 
jaundice  greatly  adds  to  its  gravity,  has  been  described  under  this 
name.  A  mild  icterus  is  sometimes  observed,  and  other  deviations  from 
the  usual  course  are  not  uncommon. 

Complications  axe  not  frequent.  The  most  important  are  pneumonia, 
nephritis,  hematuria,  hematemesis,  rupture  of  the  spleen,  and  paralyses. 
Iritis  and  other  ocular  affections  are  encountered.  Pregnant  women  fre- 
quently abort. 

Diagnosis. — The  disease  often  passes  unrecognized  until  the  first  re- 
lapse occurs.  Examination  of  the  blood  during  a  paroxysm  reveals  the 
spirilla. 

The  prognosis  is  favorable  except  in  the  bilious  form  or  after  repeat- 
ed relapses  with  complications. 

Treatment. — Beneficial  action  is  claimed  for  quinin,  calomel,  arsenic, 
methylene  blue,  potassium  iodid,  and  other  remedies,  but  there  is  no 
unanimity  of  opinion  in  regard  to  any  of  them.  Hydrotherapy  is  bene- 
ficial, although  the  spirilla  are  capable  of  prolonged  life  in  blood  of 
normal  temperature.  Injection  of  serum  from  immunized  animals  has 
been  resorted  to  during  the  first  afebrile  period,  with  arrest  of  the  disease 
in  about  half  the  cases  treated.  In  other  respects  the  treatment  is  symp- 
6 


82    .  PRACTICE  OF  MEDICINE 

tomatic.  The  strength  of  the  patient  must  be  supported  and  the  special 
symptoms  and  comphcations  must  be  combated  as  they  arise,  by  the 
methods  employed  in  typhoid  and  other  fevers. 

INFLUENZA. 

LA  GRIPPE— THE  GRIP,  CATARRHAL  INFLUENZA,  EPIDEMIC  INFLUENZA. 

Definition. — An  acute  endemic  or  epidemic,  often  pandemic,  infection 
caused  by  the  bacillus  of  Pfeiffer  and  characterized  by  a  strong  tendency 
to  attack  the  respiratory  mucous  membranes. 

Eiiology. — The  bacillus  of  Pfeififer  is  found  in  the  blood  and  nasal 
mucus,  but  more  abundantly  in  the  bronchial  secretion,  during  the 
attack  and  sometimes  for  a  long  time  after.  It  is  a  small,  short,  non- 
motile  rod  with  bulbous  ends,  staining  freely  with  a  dilute  aqueous  solu- 
tion of  carbol-fuchsin.  The  disease  is  highly  contagious  and  spreads  with 
rapidity.  Some  investigators  think  that  it  can  be  carried  by  the  air, 
and  there  is  some  evidence  of  its  transmission  by  a  third  person  or  by 
fomites.  Epidemics  are  more  frequent  during  the  winter,  but  have 
occurred  in  the  warmer  months.  Adults  are  more  susceptible  than  chil- 
dren, but  no  age  is  exempt.  In  pandemics  few  are  spared.  One  attack 
renders  the  individual  more  liable  to  future  infection.  Sporadic  cases 
usually  occur  for  several  years  after  an  epidemic.  The  common  sporadic 
influenza  is  a  separate  infection  (influenza  nostras),  but  its  etiology  is 
not  known.  The  influenza  poison  is  thought  to  be  antagonistic  to  that 
of  malaria,  since  a  marked  decrease  in  the  prevalence  of  the  latter  dis- 
ease has  been  observed  during  an  epidemic  of  the  former. 

Symptoms. — The  disease  appears  in  so  many  forms  that  it  is  cus- 
tomary to  consider  them  separately.  Clinically,  however,  the  distinction 
is  not  always  clear,  for  one  type  may  blend  with  another  or  merge  into 
it.  The  incubation  varies  from  one  to  four  days.  Prodromal  lassi- 
tude., headache,  and  dullness  are  sometimes  observed. 

General  Syfnptoms. — A  train  of  symptoms  is  more  or  less  common  to 
all  cases.  The  invasion  is  generally  abrupt,  with  a  chill  or  chilly  sen- 
sations and  a  rapid  rise  of  temperature,  often  to  104°  or  105°  F.  (40° — 
40.5°  C.),  intense  headache,  tenderness  and  aching  of  the  muscles  and 
joints,  which  are  independent  of  motion.  Mental  and  physical  depression, 
restlessness,  and  insomnia  are  often  extreme.  Catarrhal  symptoms  are 
generally,  though  not  invariably,  present.  Franke  has  recently  called 
attention  to  a  peculiar  redness  of  the  mucous  membrane  of  the  mouth, 
particularly  the  gums  and  tongue,  with  swelling  of  the  papillse  at  the 
extremity  of  the  tongue  often  equal  to  that  seen  in  scarlatina.  He 
regards  it  as  pathognomonic  of  the  disease.  The  temperature  pursues 
an  irregular  course  and  not  infrequently  terminates  by  crisis.  The  pulse 
is  usually  rapid  and  feeble,  sometimes  intermittent;  in  other  cases  it  is 
extremely  slow  (bradycardia). 

Respiratory  Type. — This  is  the  most  frequent  form.  It  may  affect  the 
entire  respiratory  system  from  the  nose  to  the  air-cells.  The  symptoms 
are  much  the  same  as  those  of  an  ordinary  catarrhal  fever,  but  the 
fever  is  more  intense  and  the  prostration  greater.  There  is  frequent 
sneezing,  sufi^usion  of  the  eyes  and  lachrymation,  often  accompanied 
with  pharyngeal  irritation,  hoarseness,  and  cough.    The  cough  is  at  first 


INFLUENZA  83 

dry  and  excessively  irritating.  In  a  day  or  two,  however,  there  is  abun- 
dant bronchial  secretion,  which  rapidly  becomes  purulent.  The  sputum 
is  generally  of  a  pale  green  color  and  is  ejected  in  firm  lumps.  Dyspnea 
is  often  a  prominent  symptom.  Cyanosis  may  result  from  the  extension 
of  the  inflammation  to  the  finer  tubes  or  from  edema  of  the  lungs. 

Nervous  Type. — In  this  form  the  patient  is  often  suddenly  seized  with 
severe  headache,  muscular  pains  or  neuralgia,  and  profound  mental  and 
physical  prostration.  There  are  frequently  cutaneous  hyperesthesia  and 
sensitiveness  to  light  and  sound,  rigidity  and  tenderness  of  the  neck 
muscles.  Convulsions  are  not  uncommon,  and  delirium  with  hallucina- 
tions appears  in  some  cases.  Some  cases  sink  into  a  typhoid  stupor; 
the  resemblance  to  meningitis  is  often  striking.  The  analogy  to  typhoid 
fever  was  most  pronounced  in  cases  observed  by  Pelon  and  by  Feindel 
and  Froussard,  in  which  lenticular  rose-spots  appeared.  The  Widal  test 
was  negative,  however,  in  all  the  cases.  The  recovery  is  generally  slow, 
and  melancholia  and  great  mental  inactivity  often  persist  for  some 
time. 

Gastrointestinal  Type. — This  is  characterized  by  persistent  nausea  and 
vomiting,  or  by  intense  abdominal  pains  and  diarrhea.  The  fever  may 
be  high.  The  symptoms  are  often  suggestive  of  appendicitis,  if,  in- 
deed, the  appendix  is  not  sometimes  implicated.  Jaundice  sometimes 
develops. 

Complications  and  SequelcB. — Lobar  and  bronchopneumonia  are  the 
most  frequent  and  serious  complications  on  the  part  of  the  respira- 
tory system.  Both  are  peculiar  in  the  great  diversity  of  the  patho- 
logical lesions  found  in  fatal  cases.  Pleurisy  and  empyema  are  not 
infrequent.  Bronchitis  characterized  by  a  preponderance  of  streptococci 
in  the  sputum  has  been  noted,  especially  by  Forchheimer.  The  compli- 
cations on  the  part  of  the  circulatory  system  are  of  special  importance 
and  are  attributed  to  the  direct  action  of  the  influenza  toxin.  Tachy- 
cardia and  bradycardia  are  alike  frequent.  Pericarditis,  myocarditis, 
phlebitis,  and  thrombosis  are  occasionally  developed.  Endocarditis  is 
rare,  and  Sansom  attributes  the  systolic  murmur  that  is  sometimes  heard 
at  the  apex  during  or  after  the  attack  to  a  progressive  degeneration  of 
the  myocardium  which  cannot  be  compensated  for  by  hypertrophy  of 
the  ventricles.  Neuritis,  hemiplegia,  monoplegias,  myelitis,  otitis,  and 
various  affections  of  the  eye  have  been  observed.  A  pre-existent  tuber- 
culosis and  cardiac  or  renal  disease  are  always  intensified  by  an  attack  of 
influenza;  even  the  encroachment  of  old  age  sometimes  seems  to  be 
hastened  by  it. 

Prognosis. — Uncomplicated  cases  usually  terminate  in  recovery.  The 
mortality  is  due  chiefly  to  the  complications  or  to  the  aggravation  of 
pre-existent  disease.  On  this  account  the  general  mortality  list  of  a 
locality  shows  an  increase  during  the  prevalence  of  an  epidemic  which 
is  in  but  small  part  accounted  for  by  the  deaths  directly  due  to  the 
grip.  The  prognosis  is  especially  unfavorable  in  alcoholic  subjects  and 
in  very  aged  persons. 

Diagnosis. — The  disease  is  diff'erentiated  from  other  catarrhal  affec- 
tions chiefly  by  the  severity  of  the  pain  and  the  profound  prostration. 
In  the  presence  of  a  pandemic,  the  diagnosis  is  seldom  difificult.  The 
bacteriological  examination  removes  all  doubt. 


84  PRACTICE  OF  MEDICINE 

Typhoid  fever,  as  compared  with  influenza,  shows  a  longer  prodromal 
stage  and  slower  elevation  of  temperature;  epistaxis  is  frequent,  the 
rose-rash  much  more  constant.    The  Widal  test  establishes  the  diagnosis. 

Cerebrospinal  meningitis  rarely  suggests  this  disease.  The  catarrhal 
symptoms  are  usually  absent;  the  character  of  the  epidemic  is  different. 

Dengue  is  a  disease  of  warm  climates  and  is  generally  distinguishable 
by  its  peculiar  febrile  paroxysms,  early  exanthem,  and  enlargement  of 
lymph-glands. 

rrea//we/7f.— Prophylaxis  is  difficult,  but  may  be  attempted  by  gen- 
eral regard  for  the  health  and  avoidance  of  fatigue  and  loss  of  rest. 
Old  persons  should  be  as  much  as  possible  protected  from  exposure  to 
the  infection. 

The  patient  should  be  confined  to  bed  during  the  entire  attack,  in 
order  to  avoid  complications.  An  attempt  may  be  made  to  abort  the 
■disease.  With  this  end  in  view,  the  patient  should  take  a  hot  bath  the 
first  night  and  follow  it  with  a  glass  of  hot  lemonade.  He  should  then 
be  warmly  covered  in  bed  in  order  to  induce  free  sweating.  A  dose  of 
calomel,  grs.  ij  to  v  (0.13—0.32),  may  be  given,  and  followed  with  a 
Seidlitz  powder  in  the  morning.  Quinin  and  Dover's  powder  are  excellent 
remedies,  to  which  belladonna  may  be  added  to  reduce  the  coryza.  The 
fever  and  pain  are  relieved  by  5  to  lo-grain  (0.32—0.64)  doses  of  phe- 
nacetin,  to  which  2  grains  (0.13)  of  citrated  caffein  should  be  added, 
particularly  if  the  heart  is  weak.  The  prostration  calls  for  stimula- 
tion, champagne  if  the  stomach  is  irritable,  or  brandy  and  strychnin, 
gr.  1-60  to  1-40  (0.00 1— 0.0016),  three  times  daily.  One-twelfth-grain 
(0.005)  doses  of  heroin  are  best  for  the  cough.  A  menthol  and  camphor 
spray  reheves  the  nasal  and  pharyngeal  irritation.  A  solution  of  the 
extract  of  suprarenal  gland  or  of  adrenalin  ( i  :  1 000)  has  yielded  good  re- 
sults. In  the  abdominal  form  of  the  disease  the  diet  must  be  carefully 
regulated  and  in  some  cases  should  be  restricted  to  milk.  Broths, 
poached  or  soft-boiled  eggs,  milk-toast,  and  custard  may  generally  be 
allowed,  and  eggnog  and  milk  when  stimulation  is  required. 


DENGUE. 

BREAKBONE  FEVER,  DANDY  FEVER. 

Dengue  is  a  disease  of  tropical  and  subtropical  regions  and  is  most  prevalent  in  the 
East  and  West  Indies,  India,  and  Egypt.  It  is  usually  confined  to  the  coast  and  val- 
leys, but  in  1870-73  it  spread  over  the  whole  of  India.  During  the  warmest  weather 
it  sometimes  invades  the  more  northern  countries.  In  1880  it  reached  Charleston,  S.  C, 
and  Augusta,  Ga.,  and  in  1897  and  189S  it  prevailed  to  some  extent  in  Georgia  and 
Florida. 

Definition. — An  acute  epidemic  or  pandemic  exanthematous  infection 
occurring  in  two  febrile  paroxysms  with  excruciating  pains  in  the  head 
muscles  and  joints. 

Etiology. — A  specific  germ  has  not  been  demonstrated.  The  infectious 
agent  is  generally  believed  to  be  conveyed  by  the  air,  by  fomites,  or  by 
direct  contact.  It  is  exceedingly  virulent,  often  attacking  fully  75  per 
cent   of  the  inhabitants  of  a  district  within  a  few  weeks.     Heat  and 


DENGUE  85 

Kumidity  favor  its  transmission.  Susceptibility  is  almost  universal  and 
uninfluenced  by  age  or  sex.  The  recent  investigations  of  Graham,  of 
Beyrouth,  indicate  that  the  mosquito  (culex)  ma}^  inoculate  the  disease. 
He  carried  mosquitoes  that  had  bitten  dengue  patients  up  into  the 
mountains,  far  from  any  recognized  source  of  infection,  and  saw  the 
disease  develop  in  two  healthy  young  men  who  voluntarily  submitted 
to  their  bites. 

Symptoms. — The  incubation  lasts  three  to  five  days.  The  attack 
consists  of  three  periods,  two  febrile  paroxysms  and  the  interval.  The 
invasion  is  generally  abrupt,  with  chilliness,  sometimes  a  rigor,  rise 
of  temperature  to  103°  F.  (39.5°  C.)  or  higher,  even  to  107°  F. 
(41.5°  C),  prostration,  and  excruciating  pains  in  the  eyeballs  or  back 
of  the  head,  the  loins,  and  limbs.  A  deep  flushing  of  the  face  may  be 
the  first  symptom.  The  tongue  is  furred;  gastric  oppression  and  vomit- 
ing may  occur.  The  initial  rash  often  invades  the  entire  body  and  the 
visible  mucous  membranes.  An  area  around  the  eyes  often  becomes  a 
deep  purple.  The  throat  may  be  congested  and  sore.  This  stage  lasts 
from  one  to  four  days ;  it  often  terminates  by  crisis  with  profuse  sweat- 
ing, diarrhea,  diuresis,  or  epistaxis.  The  pain  subsides,  and  the  patient, 
although  weak,  may  feel  well. 

The  interval  lasts  but  three  or  four  days,  then  there  is  a  return  of 
fever  and  pain,  with  a  roseolar  eruption  (the  terminal  stage).  The 
relapse  is  usually  milder  than  the  first  paroxysm;  either  the  fever  or 
the  eruption  may  escape  notice.  Reddish  brown  spots  appear  on  the 
palms  and  backs  of  the  hands,  with  prickling  and  tingling,  and  quickly 
spread.  On  the  body  the  spots  coalesce  into  areas  of  variable  size  or 
into  an  unbroken  mantle.  The  attack  lasts  only  a  few  hours  or  several 
days.  A  furfuraceous  desquamation  follows,  which  may  last  three  weeks. 
Recovery  is  usually  rapid.  Relapses  are  common.  Convalescence  may 
be  delayed  by  continuance  of  the  pains,  anorexia,  and  weakness;  and 
boils,  urticaria,  or  other  eruptions,  with  intense  pruritus,  may  occur. 
Other  complications  and  sequelae  are  rare. 

Diagnosis.— In^lnenza.,  malaria,  rheumatism,  and  yellow  fever  are  to 
be  excluded.  InJIiienza  is  a  disease  of  colder  chmates  and  winter.  It  is 
characterized  by  catarrhal  symptoms  without  eruption,  adenitis,  or  inter- 
mission. The  bacillus  may  be  found  in  the  nasal  and  bronchial  secre- 
tions. Malaria  is  excluded  by  the  chills  or  continued  fever,  the  absence 
of  coryza,  and  the  presence  of  the  Plasmodium  in  the  blood.  Both  artic- 
ular and  muscular  rheicmatism  are  more  frequent  in  the  cold  months 
and  in  regions  exempt  from  dengue.  They  have  no  eruptions  or  inter- 
missions. Sweating  is  profuse  in  the  articular  form,  seldom  in  dengue. 
The  continued  fever,  albuminuria,  jaundice,  black  vomit,  and  grave 
nervous  manifestations  oi  yellow  fever  are  distinctive. 

The  prognosis  is  good.  Fatal  convulsions  may  occur,  however,  in 
young  children.  A  malignant  type  of  the  disease  with  fatal  edema  of 
the  lungs  has  been  seen  in  Calcutta. 

Treaf.menf. — This  is  directed  to  the  relief  of  pain  and  the  support 
of  strength.  Light  liquid  diet,  rest,  the  avoidance  of  chill,  the  adminis- 
tration of  a  saline  diaphoretic  with  aconite,  and  cold  applications  to  the 
head  at  the  outset  are  recommended  by  Manson.  Phenacetin  and  bella- 
donna relieve  the  pain;  morphin  may  be  required.     Stimulants  should  be 


86  PRACTICE  OF  MEDICINE 

avoided.    During  convalescence  small  doses  of  potassium  iodid  and  qui- 
nin,  with  the  application  of  electricity,  are  beneficial, 

CHOLERA. 

ASIATIC  CHOLERA,   EPIDEMIC  CHOLERA. 

Cholera  belongs  to  India.  It  has  prevailed  there  almost  annually  for  centuries,  re- 
peatedly becoming  pandemic  and  spreading  over  Asia  and  a  great  part  of  Europe.  It 
did  not  reach  America  until  1832,  when  it  was  brought  by  emigrant  ships  to  Quebec 
and  New  York.  Cases  occurred  also  in  1835-36.  Entering  at  New  Orleans  in  1848, 
it  extended  up  the  Mississippi  and  westward  to  California,  and  recurrences  'appeared  in 
1849.  In  1854  it  again  entered  at  New  York  and  spread  over  a  greater  part  of  the 
country.  Mild  epidemics  occurred  in  1866,  1867,  and  1873.  A  remarkable  reduction  in 
its  prevalence  in  the  Philippine  Islands  has  been  noted  since  the  advent  of  United  States 
control. 

Definition. — ^An  acute  infectious  epidemic  disease  caused  by  the  com- 
ma bacillus  of  Koch,  and  characterized  clinically  by  severe  purging  and 
vomiting,  with  collapse  that  often  proves  fatal. 

Etiology. — ^The  comma  bacillus,  or  spirillum,  is  conveyed  to  the  hu- 
man being  by  drinking-water  or  food  which  it  has  contaminated.  It 
is  capable  of  living  on  meat,  milk,  butter,  or  other  raw  food  for  a  week, 
in  water  for  perhaps  a  longer  time.  The  ultimate  source  of  infection  is 
always  a  previous  case.  The  germs  are  found  in  great  numbers  in  the 
dejections  and  the  vomit  of  patients.  They  flourish  outside  of  the  body, 
however,  under  the  influence  of  heat  and  moisture,  particularly  in  cess- 
pools and  decomposing  animal  matter.  Infection  is  favored,  therefore, 
by  hot  weather,  bad  sanitation,  and  uncleanly  habits.  The  poison  is 
carried  in  such  articles  as  clothing  or  baled  rags,  but  not  by  the  air. 
Caravans  and  ships  have  been  the  principal  carriers  of  it.  The  disease 
is  not  highly  contagious  so  long  as  contamination  is  avoided.  Washer- 
women are  more  exposed  than  nurses.  Students  have  become  infected 
while  working  in  the  laboratory  with  the  cultures.  The  disease  prevails 
best  at  or  near  the  sea-level  and  rarely  reaches  the  higher  altitudes. 

Age  and  sex  are  of  little  importance  in  etiology.  Fear,  and  physical 
debility  from  age,  intemperance,  or  illness,  favor  infection  and  retard 
recovery. 

Bacteriology. — The  cholera  vibrio  is  an  actively  motile  organism  re- 
sembling a  comma  or  an  S.  It  is  about  half  as  long  and  thicker  than 
the  tubercle  bacillus.  It  grows  rapidly,  but  is  not  extremely  tenacious 
of  life.  Drying  or  exposure  to  the  air  for  three  hours  kills  it.  It  will 
live  in  water  rich  in  organic  matter  for  a  month  or  more.  It  gi-ows  best 
at  a  temperature  between  86°  and  104°  F.  (30°— 40°  C).  A  temper- 
ature of  104°  F.  (40°  C.)  destroys  it,  but  freezing  does  not.  In  the  body 
it  is  anaerobic;  without,  it  is  aerobic.  There  is  probably  no  natural 
immunity  further  than  that  afforded  by  the  power  of  the  healthy 
gastric  juice  to  destroy  the  bacilli.  But  living  bacilli  have  been  found 
in  the  stools  of  healthy  men  during  an  epidemic.  It  is  noteworthy  also 
that  lower  animals  are  not  infected  by  cultures  introduced  into  the 
stomach  unless  the  gastric  juice  has  first  been  neutralized. 

Morbid  Anatomy.— The  body  appears  emaciated  and  shrunken,  the 
face  drawn,  and  the  skin  of  dependent  portions  mottled.    A  post-mor- 


CHOLERA  87 

tern  elevation  of  temperature  is  often  noted.  Rigor  mortis  comes  on 
early  and  is  extremely  developed,  and  muscular  contractions  frequently 
occur  after  death  which  cause  the  eyes,  jaws,  or  limbs  to  move  or  the 
whole  body  to  change  its  position.  In  fulminant  cases,  dying  within  the 
first  three  or  four  hours,  there  are  no  internal  lesions,  except  frequently 
a  distention  of  the  bowels  with  a  flocculent  fluid.  In  ordinary  cases  the 
tissues  appear  dry,  the  serous  membranes  feel  sticky.  The  blood  is 
dark  and  concentrated.  The  intestines  are  shrunken  and  thin,  often  con- 
gested throughout.  Within  them  is  found  a  thin  flocculent  serum,  the 
same  as  constitutes  the  "rice-water"  dejecta  so  characteristic  of  the 
disease.  The  flocculi  consist  of  desquamated  epithelium  and  large  num- 
bers of  the  spirilla  and  other  micro-organisms.  The  spirilla  are  found 
also  in  the  ntestinal  walls  and  lymph-vessels  in  cases  that  have  not 
been  rapidly  fatal.  Parenchymatous  degenerations  and  sometimes  areas 
of  coagulation  necrosis  and  desquamation  of  tubular  epithelium  are 
found  in  both  the  liver  and  kidneys.  The  spleen  is  usually  small.  The 
heart  is  dark,  and  the  left  ventricle,  as  a  rule,  is  contracted.  The  lungs 
are  congested,  particularly  at  the  bases. 

Symptoms. — The  period  of  incubation  usually  lasts  from  two  to  five 
days;  it  is  perhaps  shorter  in  some  cases.  It  may  pass  without  symp- 
toms, or  it  may  be  marked  by  abdominal  distress,  slight  pain  and 
tenderness,  visible  peristaltic  movement,  or  moderate  diarrhea  and  de- 
pression. This  stage  is  sometimes  called  the  prodromus.  The  course  of 
the  disease  is  generally  divided  into  three  stages,  that  of  serous  diarrhea, 
t-hat  of  collapse  (or  the  algid  stage),  and  the  stage  of  reaction. 

I.  The  Stage  of  Serous  Diarrhea. — Following  the  prodromal  symptoms 
the  discharges  become  more  frequent  and  more  profuse,  or,  if  no  pro- 
dromes have  been  present,  the  onset  is  indicated  by  a  rapid  succession 
of  thin,  copious  dejections,  with  or  without  severe  griping  pain  and 
tenesmus.  Extreme  prostration  and  collapse,  with  violent  cramps  in  the 
legs  and  feet,  sometimes  precede  the  diarrhea.  Urgent  thirst  develops, 
and  persistent  vomiting  follows  within  a  few  hours,  first  of  the  undigested 
contents  of  the  stomach,  later  of  transuded  fluids.  Hiccoughing  often 
accompanies  it.  After  the  normal  fecal  matter  has  been  discharged,  the 
stools  become  thin  and  almost  clear,  often  having  a  specific  gravity 
below  i.oio  and  an  alkaline  reaction.  They  contain  flocculi  which  give 
them  the  "  rice-water"  appearance.  Blood  is  rarely  present.  The  collapse 
rapid'ly  becomes  extreme.  The  face  appears  shrunken,  and  often  has  a 
bluish,  livid  color;  the  lips  are  almost  black;  the  conjunctivae  dry  and 
congested,  the  pupils  small,  and  the  eyes  have  a  vacant  stare.  The 
cheeks  alone  are  flushed.  The  mouth  is  drawn  and  the  nose  is  pinched, 
the  alge  vibrate.  The  abdomen  becomes  flat  and  flabby.  The  patient 
appears  to  dry  up.  All  the  secretions  become  diminished  and  are  finally 
arrested,  with  the  exception,  it  is  stated,  of  the  lacteal  secretion  in 
nursing  women.  Total  suppression  of  the  urine  may  last  for  days. 
Violent  cramps  develop  in  the  abdomen  as  well  as  in  the  legs.  Emacia- 
tion becomes  extreme.  The  skin  is  "icy"  cold  and  hangs  in  folds.  A 
young  person  appears  old  and  wrinkled  within  a  day.  The  rectal  tem- 
perature mo.y,  however,  register  102°  F.  (39°  C).  In  fulminant  cases 
death  often  occurs  before  the  diarrhea  has  commenced  (cholera  sicca), 
and,  owing,  perhaps,  to  paralysis,  the  intestine  is  found  distended  with 


88  PRACTICE  OF  MEDICINE 

the  fluid.     The  stage  of  diarrhea  may  last  from  2  to  24  hours  and  then 
merges  into  the  algid  stage. 

2.  Tke  Algid  Stage,  or  Stage  of  Collapse  or  Asphyxia. — This  results  from 
the  extreme  concentration  of  the  blood,  and  the  feebleness  of  the  heart 
which  permits  it  to  stagnate  in  the  capillaries.  Respiration  becomes 
feeble  and  cyanosis  develops.  Tonic  spasms  seize  the  muscles  of  the 
abdomen,  arms,  and  legs,  and  the  suffering  is  intense.  The  voice  is  lost. 
The  pulse,  if  discernible,  is  inoderately  rapid,  100  to  120,  but  soon 
fades  away,  as  the  patient  sinks  into  a  coma.  The  alvine  discharges 
become  converted  into  a  constant  dribbling  from  the  relaxed  anus. 
Death  may  occur  from  asphyxia  or  from  heart-failure.  Not  infrequently 
the  patient  lies  for  hours  in  a  state  so  close  to  death  that  it  is  difficult 
to  determine  at  what  moment  life  becomes  extinct.  In  other  cases  a 
typhoid  condition  develops,  with  rise  of  temperature,  full  or  flickering 
pulse,  and  delirium.  This  is  sometimes  accompanied  by  a  "cholera 
eruption,"  a  roseola,  erythema,  or  urticaria.  It  may  finally  end  in  re- 
covery, but  usually  passes  again  into  fatal  collapse,  whi^ch  has  been 
attributed  to  uremia. 

3.  Stage  of  Reaction. — ^When  the  patient  passes  the  stage  of  collapse, 
his  condition  gradually  improves,  with  a  cessation  of  the  diarrhea, 
vomiting,  and  cramps;  the  skin  becomes  warm  and  the  secretions  are 
restored.  The  convalescence  lasts  two  or  three  weeks.  Diarrhea  may 
persist.    Relapse  often  occurs. 

Cholerine. — During  an  epidemic  not  a  few  cases  of  so-called  cholerine 
are  encountered,  cases  with  diarrhea,  cramps,  and  prostration  of  a 
milder  character  than  belong  to  true  cholera  and  without  complete 
collapse  or  anuria. 

Complications  and  Sequelae. — Albuminuria  often  follows  the  anuria, 
and  the  fatal  issue  is  often  attributed  to  uremia  or  sepsis.  Bedsores, 
superficial  ulcers,  furuncles,  occasionally  gangrene  and  diphtheritic  inflam- 
mation of  the  mucous  membrane  of  the  throat,  colon,  or  genitals,  have 
been  observed.  Abscesses  sometimes  form,  especially  in  the  parotid 
gland.    Broncho-pneumonia  develops  in  some  cases. 

Diagnosis.— it  is  only  the  first  cases  in  an  epidemic  that  occasion 
difficulty.  Cases  of  cholera  nostras  are  sometimes  almost  identical  with 
true  cholera.  A  serum  reaction  similar  to  the  Widal  test  has  been  found 
almost  universally  present  in  a  considerable  number  of  cases,  with  serum 
diluted  from  i  :io  to  i  :ioo,  and  as  early  as  the  first  or  second  day. 
But  the  bacteriological  examination  is  more  conclusive.  A  gelatin  cul- 
ture from  the  dejections  will  produce  a  characteristic  growth  in  a  few 
hours. 

Prognosis. — The  mortality  in  different  epidemics  varies  from  40  to 
90  per  cent.  Much  depends  upon  the  physical  condition  of  the  patient 
and  no  less  upon  the  promptness  of  the  treatment. 

Prophylaxis.— T\\Q  patient  should  be  isolated  and  a  strict  quarantine 
established.  It  is  only  as  a  result  of  our  national  quarantine  methods 
that  the  disease  has  been  kept  out  of  this  country  for  the  last  30  years. 
The  most  rigid  antiseptic  measures  must  be  practiced.  All  discharges 
from  the  patient  should  be  immediately  treated  with  a  strong  disinfec- 
tant solution  and,  if  possible,  destroyed  by  fire.  The  same  solutions 
and  methods  of  disinfection  may  be  employed  as  in  typhoid  fever.     (See 


YELLOW  FEVER 


89, 


p.  72.)  Articles  that  have  come  into  contact  with  the  patient  should 
be  burned  01  thoroughly  disinfected  and  exposed  for  days  to  the  sun's 
rays.  The  dead  should  be  disinfected  and  immediately  placed  in  a  her- 
metically sealed  coffin  or  cremated.  Water  used  for  drink  or  for  bathing 
should  be  boiled,  and  market  vegetables  and  fruit  should  not  be  eaten 
raw. 

Treatment. — A  full  hypodermic  dose  of  morphin,  gr.  Yi  to  Yz  (0.02 
— 0.03),  should  be  administered  immediately,  and  repeated  upon  return 
of  the  pain.  This  should  be  followed  with  the  deodorized  tincture  of 
opium  in  doses  of  20  drops  (0.75)  at  intervals  sufficiently  short  to  hold 
the  case  under  control  and  to  keep  the  patient  quiet.  AH  food  must  be 
withheld  during  the  diarrheal  and  algid  stages.  The  thirst  may  be 
relieved  with  chipped  ice  and  ice-water  acidulated  with  dilute  hydro- 
chloric acid,  gtt.  XXX  every  two  hours,  since  it  is  antagonistic  to  the 
bacilli.  Strength  should  be  maintained  with  brandy  and  black  coffee 
by  the  rectum,  and  strychnin  nitrate  hypodermically  in  doses  of  gr.  1-20 
(0.003).  After  vomiting  has  been  checked,  milk  may  be  given  in  small 
quantities  at  regular  intervals.  The  surface  temperature  must  be  main- 
tained by  applications  of  dry  heat,  and  the  abdominal  pains  relieved  by 
hot  fomentations. 

Saline  injections  afford  a  most  valuable  means  of  counteracting  the 
depletion  of  the  blood.  The  normal  salt  solution  is  injected  into  the 
subcutaneous  tissue  of  the  abdomen  at  a  temperature  of  104^  F.  (40° 
C),  allowing  from  one  to  two  quarts  (liters)  to  flow  by  gravity  through 
the  hypodermic  needle.  Enterodysis  often  produces  excellent  results. 
From  two  to  four  quarts  of  a  2-per-cent  solution  of  tannic  acid  at  a 
temperature  of  110°  F.  (43 ^^  C.)  should  be  injected,  preferably  through 
the  long  rectal  tube.  Both  these  measures  are  useful  in  overcoming  the 
anuria. 

Antitoxin  Treatment. — Better  results  have  been  reported  from  the  use 
of  this  method  as  a  prophylactic  measure  than  in  treatment.  The  inocu- 
lation is  made  first  with  a  weak  culture,  and  five  days  later  with  a 
stronger  one.  Immunity  develops  in  five  days  after  the  second  inocu- 
lation. 

YELLOW  FEVER. 

BLACK  JACK,  THE  BLACK  VOMIT. 

Yellow  fever  is  endemic  in  the  tropics,  Guiteras  has  given  us  the  foJlowing  useful 
classification  of  the  areas  of  infection  :  i.  The  focal  zone,  from  which  the  disease  is  never 
absent,  including  Havana,  Vera  Cruz,  Rio,  and  other  Spanish-American  ports.  2.  Peri- 
focal zones,  or  regions  of  periodic  epidemics,  including  the  ports  of  the  tropical  Atlantic 
in  America  and  Africa.  3.  The  zone  of  accidental  epidemics,  between  the  parallels  of 
45°  N.  and  35°  S.  latitude.  It  is  noteworthy,  however,  that  under  the  supervision  of 
the  United  States  authorities,  Havana  has  been  removed  from  the  first  to  the  second 
or  third  of  these  classes. 

Definition.— Axi  acute  infectious  disease  probably  caused  by  the  ba- 
cillus icteroides,  and  having  as  its  most  distinguishing  features  a  peculiar 
jaundiced,  congested  facies,  fever  with  slow  pulse,  hematemesis  (black 
vomit),  and  albuminuria  or  total  suppression  of  the  urine. 

Etiology.— The  bacillus  icteroides,  of  Sanarelli,  is  now  generally  ac- 
cepted as  the  cause.    It  is  a  slender,  motile,  facultative,  anaerobic  ba- 


90  PRACTICE  OF  MEDICINE 

cillus  from  2  to  4/^  in  length.  Its  etiological  relation  is  supported :  (i) 
by  its  frequent  presence  in  the  blood  and  viscera  of  the  dead,  (2)  by 
a  serum  test  in  which  the  bacilli  become  agglutinated  and  motionless 
after  the  manner  of  typhoid  bacilH  in  the  Widal  test,  and  (3)  by  the 
production  of  the  disease  in  man  through  inoculation  experiments  con- 
ducted by  Sanarelli  and  others.  The  disease  is  not  directly  contagious, 
and  recent  investigations  apparently  disprove  the  old  behef  that  the 
poison  is  carried  by  fomites.  If  the  investigations  made  by  the  Com- 
mittee of  the  Pan-American  Medical  Congress  be  correct,  the  disease  is 
produced  only  by  inoculation,  and  the  only  known  mode  of  its  trans- 
mission from  one  individual  to  another  is  by  the  mosquito  (^Stegomyia 
fasciata).  This  discovery  supports  the  old  theories  that  the  disease 
is  most  infectious  at  night  and  in  low-lying  districts,  and  that  it  may 
be  carried  to  some  distance  by  air-currents.  The  same  investigations 
seem  to  show  that  the  bacillus  remains  in  the  body  of  the  mosquito 
from  12  to  18  days,  the  length  of  time  depending  upon  the  temper- 
ature of  the  air,  before  it  can  be  inoculated  into  a  human  being.  The 
recent  investigation  in  regard  to  the  transportation  of  mosquitoes  on 
shipboard,  taken  in  connection  with  these  probable  facts,  seems  to  explain 
the  sudden  outbreak  of  the  disease  in  places  remote  from  a  known 
center  of  infection,  as  in  Galveston,  in  1897,  after  an  absence  of  30 
years,  an  occurrence  which  occasioned  much  discussion  and  no  little 
criticism  of  the  physicians  who  recognized  the  character  of  the  disease. 

Season.— Tht  disease  is  favored  by  high  temperature,  from  72°  F. 
(22°  C.)  and  upward,  and  by  a  high  degree  of  humidity.  It  is  quickly 
a-rrested  by  frost,  which  kills  the  mosquito,  but  freezing  does  not  entirely 
devitalize  the  bacillus.  In  tropical  countries  it  may  prevail  the  year 
round.    It  usually  reaches  our  shores  in  the  autumn. 

Age  and  Sex.— The.  disease  attacks  people  of  all  ages,  but  is  less  fre- 
quent toward  either  extreme  of  life.  Children  appear  more  susceptible 
than  adults.  Infants  have  the  disease,  if  at  all,  in  a  mild  form.  The 
negro  is  to  a  certain  extent  immune  and  usually  recovers. 

During  an  epidemic  such  influences  as  fatigue,  heat  prostration,  worry, 
fear  of  the  disease,  alcoholism,  and  debauchery  increase  susceptibility. 

Immunity. — One  attack  generally  confers  immunity,  but  second  attacks 
have  been  observed.  Protracted  residence  in  the  North  and  long  absence 
of  the  disease  from  a  locality  are  thought  to  overcome  immunity.  The 
question  arises,  may  not  the  immunity  be  sustained  by  repeated  inocu- 
lation of  the  disease  by  the  mosquito? 

Morbid  Anatomy. — The  skin  is  jaundiced,  and  ecchymoses  are  fre- 
quently seen  in  it.  The  icteric  hue  is  said  to  deepen  after  death.  The 
urine  and  other  fluids  are  yellow.  The  blood  shows  little  change  in 
cases  of  moderate  severity.  The  bacillus  is  occasionally  found  in  it. 
In  severe  cases  free  hemoglobin  is  found  in  the  blood-serum  as  a  result 
of  destruction  of  the  red  corpuscles,  and  these  corpuscles  usually  show 
degenerative  changes.  Fatty  or  other  degeneration  is  more  or  less  con- 
stantly found  in  the  heart,  liver,  and  kidneys.  The  liver  in  early  cases 
is  congested,  but  in  cases  of  longer  duration  it  is  pale.  The  hepatic 
cells  show  fatty  degeneration  and  necrosis,  and  the  small  bile-ducts  are 
gorged  with  desquamated,  degenerated  epithelium.  The  bile  in  the 
gall-bladder  is  thick  and  dark.    The  brain  and  meninges  are  congested. 


YELLOW  FEVER  91 

Hemorrhagic  infarcts  are  sometimes  found  in  the  lungs  and  elsewhere. 
The  mucous  membranes,  particularly  of  the  stomach,  show  ecchymoses 
and  erosions,  and  similar  changes  are  found  in  the  serous  membranes. 
The  black,  tarry  matter  which  constitutes  the  black  vomit  is  found  in 
the  stomach  and  intestines  of  hemorrhagic  cases. 

Symptoms.— The  incubation  period  is  from  iS  hours  to  a  week, 
usually  three  or  four  days,  being  shorter  in  proportion  to  the  severity 
of  the  disease.  Prodromes  are  usually  absent.  The  invasion  is  sudden 
and  generally  occurs  in  the  morning  hours.  The  clinical  history  is 
divided  into  three  stages  : 

J^trsf  Stage. — Chilly  sensations,  sometimes  a  rigor,  or  in  children  a 
convulsion,  with  headache,  severe  pains  in  the  back  and  calves  of  the 
legs,  are  almost  constant  symptoms.  The  temperature  rises  during  the 
chill  to  103*^  or  105°  F.  (39.5" — 40.5°  C).  The  cheeks  and  conjunc- 
tivae immediately  become  bright  red  with  capillary  dilatation.  The 
eyes  are  watery  and  staring.  The  lips  and  eyelids  are  generally  puffy, 
and  a  slightly  icteric  tinge  may  be  detected  in  the  conjunctivae  and  skin 
of  the  face  on  careful  examination,  often  on  the  first  day.  These  ap- 
pearances are  characteristic  of  the  disease.  Vomiting  begins  on  the 
first  day,  as  a  rule;  the  vomitus  consists  first  of  the  contents  of  the 
stomach,  then  of  a  thin,  grayish  mucus,  and  finally,  in  severe  cases,  of 
blood.  The  pulse  is  seldom  over  100,  full  and  soft,  in  the  beginning,  and 
becomes  slower  and  more  feeble  as  the  disease  progresses,  until  it  is 
perhaps  50  or  less.  The  epigastrium  is  so  sensitive  that  slight  pres- 
sure causes  vomiting.  The  tongue  is  dry  and  pointed,  the  gums  swollen 
and  red,  often  bleeding.  The  skin  is  at  first  dry;  it  sometimes  becomes 
moist  and  then  has  a  peculiarly  offensive  odor.  The  urine  is  scant,- 
highly  acid,  and  albuminous,  particularly  in  the  evening.  By  the  second 
or  third  day  the  jaundice  deepens  to  a  saffron  color.  The  temperature, 
as  a  rule,  remains  high  until  the  third  or  fourth  day,  then  subsides  and 
often  becomes  subnormal. 

Second  Stage. — This  is  known  also  as  the  ''calm"  or  "remission." 
With  the  decline  of  the  temperature  the  other  symptoms  abate  and  the 
patient  experiences  a  relief.  In  children  this  may  occur  as  early  as  the 
second  day.  In  mild  cases  it  is  permanent  and  marks  the  beginning 
of  convalescence.  In  another  group  of  cases  destined  to  recover,  the 
convalescence  is  delayed  by  recrudescence  of  two  or  three  days,  with 
irregular  reactionary  fever.  In  severe  cases,  however,  the  calm  lasts  but 
a  few  hours,  possibly  3  6,  'and  the  patient  rapidly  declines  into  a  collapse. 

Third  Stage,  or  Collapse. — This  is  marked  by  suppression  of  urine  and 
hemorrhages  from  the  mucous  membranes,  particularly  of  the  stomach. 
Fever  may  be  present,  but  the  temperature  sometimes  remains  normal. 
In  fatal  cases  it  often  rises  to  108°  or  110°  F.  (43°  C.)  before  death. 
The  disease  is  of  short  duration,  not  usually  exceeding  a  week.  Re- 
lapses occasionally  occur. 

Special  Symptoms. — Fades. — Even  on  the  morning  of  the  first  day 
the  face  is  flushed  more  than  in  any  other  acute  infection,  and  the  eye- 
lids and  lips  are  swollen.  The  superficial  capillaries  of  the  face  and 
those  of  the  conjunctivae  are  dilated,  and  on  close  examination  slight 
icterus  can  be  recognized.  The  eyes  have  a  peculiar  stare  and  a  distinc- 
tive "alertness." 


92  PRACTICE  OF  MEDICINE 

■.  Fever. — The  temperature  may  be  only  moderately  high  in  an  ordinary 
case.  After  the  initial  rise  it  often  subsides  on  the  second  day  to  102^ 
or  103°  F.  (39.0° — 39.5°  C).  It  is  then  irregular  in  its  course  and  may 
terminate  by  lysis.  A  rapid  fall  below  normal  often  precedes  collapse, 
and  a  rapid  rise  a  fatal  termination. 

The  pulse  is  slow  and  out  of  normal  ratio  (4:1)  to  the  temperature 
from  the  beginning,  and,  although  the  temperature  may  be  still  rising, 
it  becomes  progressively  slower.  It  sometimes  reaches  a  rate  of  only 
35  to  50  during  defervescence.  Occasionally  it  becomes  rapid  and  irreg- 
ular, reaching  120  or  more.  At  first  full,  it  becomes  extremely  feeble 
in  fatal  cases.  Respiration  is  usually  accelerated,  sometimes  irregular; 
dyspnea  may  be  extreme  in  the  later  stages. 

Black  Vomit. — Extreme  irritability  of  the  stomach  is  a  constant  symp- 
tom from  the  beginning.  Black  vomit  occurs  in  about  one-third  of 
the  cases.  When  the  blood  is  copious  there  is  usually  severe  pain  in 
the  stomach  and  esophagus.  Hemorrhages  from  the  gums,  nose,  eyes, 
kidneys,  and  uterus  frequently  occur,  and  petechiae  may  appear  in  the 
skin.  The  bowels  are  usually  constipated.  The  stools  have  not  the 
clay  color  of  jaundice ;  they  are  frequently  black,  from  the  presence  of 
blood. 

Albumiiiuria  generally  appears  not  later  than  the  evening  of  the  third 
day  even  in  the  mildest  cases.  An  intense  nephritis,  with  much  albumin 
and  casts,  develops  in  severe  cases;  complete  suppression  may  occur 
and  lead  to  fatal  uremia. 

■■  Mental  Condition.— \vl  mild  cases  the  mind  remains  clear  and  the 
patient  watches  all  that  transpires.  Delirium  and  coma  develop  when 
the  disease  is  severe. 

i  Clinical  Varieties.— With  regard  to  the  severity  of  the  manifestations, 
different  types  of  the  disease  have  been  recognized.  There  are  mild 
cases  with  moderate  fever,  slight  or  no  jaundice,  and  early  recovery. 
A  transitory  albuminuria  may  be  present.  "Walking"  cases  are  not 
uncommon.  A  comatose  type  is  recognized  in  which,  without  fever, 
the  patient  passes  into  a  stupor  on  the  first  or  second  day,  with  great 
prostration,  feeble  pulse,  and  albuminuria.  Death  often  ocours  on  the 
third  day.  Another  class  of  cases  is  distinguished  by  violent  delirium 
from  the  beginning. 

Complications  and  Seque/ce. — These  are  not  common  and  are  generally 
of  the  same  character  as  are  encountered  in  other  acute  infections,  as 
phlebitis  and  thrombosis  of  the  femoi"al  veins,  acute  nephritis,  and  sup- 
purative parotitis.  Fatal  hematemesis  has  followed  an  error  in  diet 
several  weeks  after  recovery.     Pregnant  women  generally  abort. 

Diagnosis. — The  three  distinguishing  features  of  the  disease,  as  em- 
phasized by  Guiteras,  are :  the  facies,  albuminuria,  and  the  slowing 
pulse,  with  maintenance  or  elevation  of  temperature.  The  urine  should 
be  examined  in  the  evening.  The  headache,  pain  in  the  calves,  gastric 
irritability,  epigastric  tenderness,  and  the  black  vomit  are  valuable  fac- 
tors in  diagnosis.  The  agglutination  test  may  be  applied  as  early  as 
the  second  day. 

Dengue. — This  is  probably  the  most  difficult  disease  to  distinguish, 
since  it  so  frequently  occurs  in  the  same  localities  and  at  the  same 
seasons  and  is  similar  in  onset  and  symptoms.     It  is    not,    however, 


YELLOW  FEVER  93 

accompanied  by  so  great  weakness,  gastric  irritability,  jaundice,  albu- 
minuria on  the  first  or  second  evening,  or  hemorrhages.  The  pulse  is 
rapid  and  the  temperature  rises  more  slowly.  An  eruption  often  appears. 
The  blood  would  probably  not  agglutinate  the  bacillus  icteroides. 

Malaria,  especially  the  irregular  remittent,  estivo-autumnal  type, 
when  accompanied  by  vomiting  and  slight  jaundice,  is  often  difficult  of 
distinction.  But  the  icterus  does  not  appear  so  early,  the  face  is  usually 
dull,  not  alert;  the  tongue  is  broad,  flat,  and  pale,  not  dry  and  pointed. 
The  discovery  of  the  plasmodium  in  the  blood  is  distinctive. 

Relapsing  fever  is  readily  recognized  by  the  discovery  of  the  spirilla 
in  the  blood,  as  well  as  by  the  slower  onset,  more  rapid  pulse,  enlarge- 
ment of  the  spleen,  and  the  absence  of  black  vomit  and  extreme  gas- 
tric irritability. 

Acute  yellow  atrophy  of  the  liver  is  accompanied  by  gradual  elevation 
of  temperature,  without  pain  or  so  great  gastric  irritability.  The  urine 
contains  large  quantities  of  bile  pigments,  leucin,  and  tyrosin. 

Acute  febrile  jaundice  (Weil's  disease)  is  characterized  by  less  severity 
of  onset  and  less  prostration ;  black  vomit,  albuminuria,  and  suppression 
are  absent. 

Prognosis.— The  death-rate  in  epidemics  is  very  different.  It  may 
be  as  low  as  10  to  20  per  cent  or  as  high  as  80  to  90  per  cent.  The 
prognosis  is  rendered  less  favorable  by  previous  debility,  anxiety  or 
fear,  alcoholism,  pregnancy,  or  the  puerperal  state.  Suppression  of  urine 
is  an  unfavorable  symptom,  and  when  this  is  accompanied  by  black 
vomit  recovery  rarely  follows.  Black  vomit  alone  is  not,  however,  ex- 
tremely dangerous.  The  virulence  of  an  epidemic  appears  to  be  greater 
in  proportion  to  the  length  of  time  that  has  elapsed  since  the  last  pre- 
ceding outbreak.  Much  depends  upon  the  promptness  with  which  treat- 
ment is  instituted. 

Prophylaxis  consists  less  in  the  inspection  and  quarantine  of  ships 
from  infected  ports  than  in  the  isolation  of  the  sick,  with  especial  refer- 
ence to  the  exclusion  of  mosquitoes.  By  the  systematic  warfare  that 
has  been  waged  upon  these  pests  and  their  larvae  during  the  last  two 
or  three  years,  Havana  has  been  freed  from  yellow  fever  for  the  first 
time  in  150  years.  Stress  has  always  been  laid  upon  the  importance  of 
burning  all  fomites,  but  if  recent  investigations  prove  to  be  correct 
this  is  not  necessary.  Susceptible  persons  have  slept  in  the  midst  of 
infected  Hnen  for  28  days  without  infection  so  long  as  mosquitoes  were 
excluded.  Sanarelli  has  used  horse  serum,  Freire  and  others  that  of 
immune  persons,  with  some  success. 

Treatment. — Good  ventilation  and  absolute  rest  are  important.  The 
patient  should  not  be  disturbed,  the  bedpan  must  be  used,  and  nourish- 
ment and  drink  must  be  given  through  a  tube.  Removal  of  the  patient 
to  other  quarters  is  harmful.  Food  should  be  administered  by  the 
rectum  during  the  period  of  gastric  irritabihty.  This  irritability  calls 
for  the  administration  of  cracked  ice,  or,  better,  iced  champagne.  Dilute 
hydrocyanic  acid  may  be  given  in  3-drop  doses.  Sternberg  highly  recom- 
mends the  following  mixture:  Sodium  bicarbonate,  grs.  cl  (10. o); 
hydrargyri  bichlorid,  gr.  Y^  (0.02);  pure  water,  Oij  (1000),  to  be  given 
in  doses  of  three  tablespoonfuls  every  hour.  It  has  been  found  to  reduce 
the  gastric  irritability,  to  maintain  the  urinary  secretion,  and  in  other 


94  PRACTICE  OF  MEDICINE 

ways  to  reduce  the  mortality.  Nunez  has  had  good  results  from  potas- 
sium bitartrate  and  salol.  Quinin  in  20-grain  (1.30)  doses  was  formerly 
much  employed.  The  cardiac  weakness,  particularly  in  the  second  stage, 
should  be  met  by  stimulation  with  brandy  and  strychnin  hypodermically 
or  by  rectum.  The  pains  may  be  in  a  measure  relieved  by  applications 
of  heat  and  sinapisms ;  some  patients  prefer  the  ice-bag.  Morphin  should 
be  used  cautiously,  if  at  all,  since  it  has  proved  a  dangerous  remedy 
(Sternberg).  For  cerebral  congestion  ice-bags  should  be  applied  to  the 
head  and  sinapisms  to  the  feet.  The  tendency  to  hemorrhage  often 
resists  treatment;  the  acetate  of  lead  and  opium  may  be  employed  with 
caution.  Good  results  have  been  obtained  from  hypodermic  injections 
of  ergotin. 

Sanarelli's  serum  treatment  is  reporte'd  to  have  proved  successful  in 
a  considerable  number  of  cases. 

During  convalescence  the  greatest  care  must  be  exercised  in  order 
not  to  overtax  the  stomach.  Alimentation  must  be  begun  cautiously; 
the  food  should  be  of  the  most  delicate  character  and  administered  in 
small  quantity.  Such  tonics  as  iron,  quinin,  and  strychnin,  separately 
or  combined,  hasten  recovery. 

THE  PLAGUE. 

BUBONIC  PLAGUE,   MALIGNANT  ADENITIS,   BLACK  DEATH. 

The  plague  is  a  disease  of  the  Orient,  where  it  has  prevailed  from  antiquity.  Its  fre- 
quent prevalence  in  the  Philippine  Islands,  its  outbreak  in  Hawaii  in  1899,  importation 
to  San  Francisco  in  1900,  and  continued  presence  in  Mexico  as  late  as  the  spring  of 
1903  have  given  it  an  importance  to  American  physicians  which  it  did  not  before  pos- 
sess. 

Dsfiniiion.—A.  virulent  acute  infectious  disease  caused  by  the  bacillus 
pestis  of  Kitasato,  running  a  rapid  febrile  course  with  bubonic  swellings 
in  different  parts  of  the  body,  and  often  accompanied  by  hemorrhages 
from  the  mucous  membranes.  Three  clinical  forms  are  usually  recognized, 
the  glandular,  the  pneumonic,  and  the  septicemic. 

EHology. — The  bacillus  pestis  has  been  proved  the  cause  of  the  dis- 
ease by  inoculation  experiments  in  animals,  as  well  as  by  its  uniform 
presence  in  the  body  after  death,  particularly  in  the  blood  and  enlarged 
glands.  The  bacillus  is  a  short,  thick  rod  with  rounded  ends.  It  is 
obtained  with  least  difficulty  from  the  bloody  sputum  of  pneumonic 
cases,  and  may  be  cultivated  on  an  alkaline  agar  medium.  It  is  believed 
to  have  an  independent  existence  outside  of  the  body,  in  the  ground. 
The  avenues  of  its  entrance  into  the  body,  it  is  generally  believed,  are 
the  mucous  membranes  of  the  respiratory  passages  and  the  cutaneous 
surface  after  injury.  The  tonsil  is  also  believed  to  be  a  possible  portal 
of  entrance.  The  poison  is  thought  to  be  carried  on  clothing,  bedding, 
and  oth^r  articles,  and  to  cling  tenaciously  to  houses  and  localities. 
Epidemics  have  followed  the  opening  of  the  graves  of  plague  victims. 
Rats,  cats,  dogs,  and  other  animals  become  infected.  Rats  especially 
are  regarded  as  carriers  of  infection,  even  to  distant  lands,  by  gaining 
entrance  into  ships.  They  often  die  in  great  numbers  before  and  during 
an  epidemic.     Flies,  bugs,  lice,  and  especially  fleas  are  also  capable  of 


THE  PLAGUE  95 

conveying  infection  to  man.  The  chief  predisposing  causes  are  over- 
crowding, filth,  and  deficient  ventilation. 

Season. — The  disease  is  favored  by  warm  weather  and  humidity,  but 
outbreaks  sometimes  occur  in  winter.  It  is  somewhat  more  frequent 
between  the  ages  of  20  and  30;  persons  over  50  are  seldom  attacked. 
Both  sexes  are  about  equally  susceptible.  It  is  believed  to  be  only 
mildly  contagious. 

Morbid  Anatomy. — The  lymph-glands  of  the  inguinal  or  the  femoral 
region,  less  frequently  those  of  the  axillse  or  neck,  are  enlarged  and 
firm,  or  in  a  state  of  suppuration.  The  overlying  skin  is  edematous 
and  much  thickened.  After  death  in  the  most  rapidly  fatal  cases,  the 
primary  bubo,  or  lymph-gland  nearest  the  site  of  inoculation,  may  be  so 
small  as  to  be  found  with  difficulty.  In  it  the  parenchyma  is  destroyed. 
Necrotic  or  hemorrhagic  areas  appear,  or  suppuration  may  have  oc- 
curred. Pyogenic  cocci  are  frequently  found  in  addition  to  the  bacillus 
pestis.  Ecchymoses  and  petechia  are  found  on  the  surface  of  various 
parts  of  the  body.  The  secondary  buboes  are  intensely  hyperemic  and 
occasionally  contain  hemorrhages.  The  various  hemorrhagic  lesions  are 
believed  to  be  the  direct  result  of  the  bacteria,  and  not  due  to  the  toxins. 
Parenchymatous  and  fatty  degenerations  of  the  heart,  liver,  and  kidneys 
are  common.  The  spleen  is  much  enlarged  and  soft,  being  distended 
with  blood  rich  in  polymorphonuclear  cells.  In  the  pyemic  form  of  the 
disease,  metastatic  foci  of  suppuration  are  found  in  the  lungs,  liver,  spleen, 
and  muscles,  often  surrounded  by  extravasated  blood.  The  lung  lesions 
in  the  pneumonic  form  are  primarily  lobular,  but  they  may  be  so  ex- 
tensive as  to  cause  the  solidification  of  an  entire  lobe.  Bronchitis  is  always 
found  and  the  bronchial  glands  have  the  appearance  of  primary  buboes. 

Clinical  Forms. — With  reference  to  its  severity,  three  forms  of  the 
disease  are  recognized.  These  are :  ( i )  Pestis  siderans,  a  rapidly  fatal 
septicemic  form;  (2)  pestis  major,  the  usual  form;  and  (3)  pestis  minor, 
a  mild  form  characterized  by  glandular  enlargements  without  pronounced 
constitutional  disturbances.  The  last  form  is  seen  particularly  in  the 
beginning  of  an  epidemic.  A  more  useful  classification,  perhaps,  is  based 
upon  the  character  of  the  pathological  lesions :  ( i )  a  glandular  type, 
(2)  a  pneumonic  type,  and  (3)  a  septicemic  type. 

Symptoms. — Glandiclar  Type. — The  incubation  period  is  usually  from 
two  to  five  days.  Headache,  pain  in  the  back  and  limbs,  vertigo  with 
a  staggering  gait,  languor,  nausea,  vomiting,  and  epistaxis  are  some- 
times complained  of  during  the  last  day  or  two  of  this  period,  A  more 
or  less  distinct  chill  follows,  with  rapid  rise  of  temperature,  usually 
to  103°  or  105°  F.  (39.5° — 40-5°  C.),  sometimes  even  above  108°  F. 
(42°  C).  The  pulse  ranges  from  120  to  150  and  the  breathing  is 
quickened.  As  the  disease  progresses,  the  headache,  nausea,  and  vomit- 
ing become  more  severe,  extreme  thirst  develops,  and  the  lymph-glands 
rapidly  enlarge.  The  face  is  intensely  flushed,  the  conjunctivae  are  con- 
gested. The  patient  may  fall  into  a  stupor,  but  in  some  cases  delirium 
develops.  After  three  or  four  days  the  glandular  swelling  becomes  ex- 
treme. By  the  involvement  of  a  group  of  glands  large  buboes  are  formed, 
the  apparent  size  being  increased  by  the  edema  of  the  overlying  tissues. 
These  are  found  especially  in  the  groin  or  along  the  femoral  groove  of 
one  or  both  legs,  less  frequently  in  the  axillae  or  neck.    The  tonsils  are 


96  PRACTICE  OF  MEDICINE 

tsometimes  similarly  involved.  The  primary  bubo  is  usually  larger  and 
in  a  later  stage  of-  development  than  the  secondary  buboes.  The  skin 
over  the  affected  glands  becomes  stretched  and  glossy.  The  swellings 
are  generally  extremel}^  painful  and  exquisitely  sensitive  to  touch.  Sup- 
puration frequently  occurs  and  is  considered  a  favorable  change.  When 
the  cervical  glands  are  involved,  dyspnea  and  venous  obstruction  are 
produced.  Carbuncles  often  form  on  the  back  of  the  neck.  The  frequent 
appearance  of  petechiae  over  the  body  has  given  the  name  "black 
death"  to  the  disease.  Leucocytosis  is  usually  present.  The  urine 
shows  the  usual  febrile  changes.  The  acute,  febrile,  period  of  the  disease 
lasts  from  3  or  4  to  lo  days.  Convalescence  is  generally  rapid,  unless 
it  be  retarded  by  the  suppuration  of  the  glands. 

2.  Pneumonic  Type.—T\\\s  begins  with  a  chill,  pain  in  the  side,  severe 
headache,  high  fever,  and  rapid  breathing,  with  signs  of  pulmonary  con- 
solidation. Extreme  dyspnea  and  cyanosis  are  often  present.  The  sputum 
is  bloody,  not  "  rusty"  as  in  lobar  pneumonia.  This  form  of  the  dis- 
ease is  nearly  always  fatal  in  from  one  to  five  days.  Broncho-pneu- 
monia sometimes  occurs  as  a  compHcation  of  the  glandular  type  of  the 
disease,  causing  it  to  resemble  the  pneumonic. 

3.  Septicemic  Type. — Cases  of  a  septicemic  character  (pestis  siderans) 
are  not  infrequently  encountered  during  an  epidemic.  The  indications 
all  point  to  a  severe  and  rapidly  fatal  sepsis.  They  usually  terminate 
within  three  days,  often  within  a  few  hours,  and  before  glandular  en- 
largement has  become  recognizable.  Even  in  these  cases,  however,  there 
is  marked  sensitiveness  over  the  regions  of  the  lymph-glands,  possibly 
over  the  entire  body,  and  frequently  there  are  hemorrhages  into  the  skin 
and  from  the  various  mucous  membranes. 

Diagnosis. — The  frequent  occurrence  of  mild  cases  in  the  beginning 
of  an  epidemic  often  prevents  the  immediate  recognition  of  the  disease. 
Septic  cases  at  this  time  are  seldom  recognized.  In  ordinary  cases  the 
mode  of  invasion,  with  the  early  tumefaction,  pain,  and  tenderness  of 
the  lymph-glands,  is  distinctive  after  the  prevalence  of  the  disease  has 
been  recognized.  Tubercular  and  venereal  buboes,  when  accompanied 
by  fever,  may  cause  temporary  uncertainty  during  an  epidemic,  but 
not  otherwise.    Other  diseases  are  sometimes  difficult  of  exclusion. 

Typhus  fever  is  accompanied  by  an  eruption,  usually  petechial  in  char- 
acter, but  the  glandular  swellings  or  pneumonic  symptoms  are  absent. 

Malaria  and  relapsing  fever  are  usually  distinguished,  if  not  by  the 
absence  of  glandular  involvement,  by  the  recognition  of  the  specific 
micro-organism  of  each  in  the  blood.  Cases  are  occasionally  observed, 
however,  in  which  one  or  the  other  of  these  affections  has  been  coin- 
cident with  the  plague. 

Prophylaxis.— This  consists  in  the  most  rigid  measures  of  sanita- 
tion in  the  infected  districts,  absolute  quarantine,  and  a  general  clean- 
ing up  of  adjacent  territory.  The  extermination  of  rats  is  essential. 
The  houses  that  have  been  occupied  by  the  patients  and  all  articles 
that  have  come  into  contact  with  them  must  be  thoroughly  disinfected 
or  destroyed.  No  measure  was  ever  more  appropriate  or  more  effective 
than  the  total  destruction  of  the  infected  district  by  fire  practiced  by 
our  Government  at  Honolulu  a  few  years  ago.  For  individual  protec- 
tion, Haffkine's  serum  may  be  used.    It  is  a  sterilized,  attenuated  bouil- 


MALTA  FEVER 


97 


Ion  culture  of  the  bacillus  pestis.    Although  it  does  not  always  afford 
complete  immunity,  the  disease  has  proved  less  virulent  after  its  use. 

Treatment. — The  general  treatment  is  wholly  supportive  and  symp- 
tomatic. The  strength  should  be  supported  by  nourishing  liquid  food 
and  brandy.  The  heart's  action  may  be  maintained  by  frequent  full 
doses  of  strychnin,  gr.  1-60  to  1-20  (o.ooi — 0.003),  ^^d  ammonium 
carbonate.  Since  suppuration  is  considered  favorable,  it  may  be  encour- 
aged by  the  application  of  hot  poultices  to  the  buboes.  The  Yersin- 
Roux  serum,  obtained  from  immunized  horses,  has  been  used  with  re- 
ported benefit  in  some  cases. 

CLIMATIC  BUBO. 

Under  the  names  chmatic  bubo  and  malarial  bubo,  various  authors 
have  described  a  nonvenereal  enlargement  of  the  inguinal  glands  which 
attacks  by  preference  young  adult  Europeans  after  a  residence  of  three 
months  or  more  in  tropical  countries.  The  disease  occurs  chiefly  at 
the  end  of  the  rainy  season  and  in  persons  who  are  suffering  from  fatigue 
or  those  run  down  and  anemic.  It  is  apparently  independent  of  any 
relation  to  malaria.  The  only  recognizable  cause  is  the  entrance  of 
micrococci  through  slight  wounds  of  the  integument  of  the  lower 
extremities  or  the  bites  of  such  insects  as  fleas  and  mosquitoes.  The 
affection  has  followed  the  dhobi  itch  and  other  skin  lesions.  The  blood- 
count  shows  anemia  and  leucocytosis.  Fever  is  usually  present,  but  it 
rarely  exceeds  101°  F.  (38°  C).  On  account  of  the  adenitis  and  fever 
the  condition  has  been  mistaken  for  the  pestis  minor,  or  mild  form  of 
bubonic  plague.  The  treatment  consists  in  the  removal  of  the  glands, 
which  promptly  arrests  all  symptoms. 


MALTA  FEVER. 

MEDITERRANEAN  FEVER,  GIBRALTAR  FEVER,  NEAPOLITAN  FEVER,  UNDU- 

LANT  FEVER. 

The  disease  is  endemic  at  Malta  and  occasionally  spreads  in  epidemic  form  along 
the  shore  of  the  Mediterranean.    It  is  also  met  with  in  the  East  and  West  Indies. 

Definition. — An  infectious  disease  caused  by  the  micrococcus  Melitensis 
of  Bruce  and  characterized  by  a  series  of  febrile  attacks  with  profuse 
sweating  and  painful  swelling  of  the  joints. 

Etiology. — The  disease  is  not  contagious.  The  infectious  agent  prob- 
ably originates  in  small  foci,  often,  apparently,  in  the  rooms  occupied 
by  a  previous  patient,  but  the  means  of  its  transmission  is  not  known. 
June,  July,  and  August  are  the  months  of  greatest  prevalence  at  Malta. 
Epidemics  sometimes  occur.  The  most  susceptible  age  is  from  6  to  30 
years.  Infants  and  the  aged  generally  escape.  Immunity  is  thought 
to  be  conferred  by  one  attack. 

Symptoms. — The  incubation  varies  from  6  to  17  days.  The  onset  is 
often  much  like  that  of  typhoid  fever,  with  anorexia,  thirst,  pain  in  the 
head,  back,  and  extremities,  and  a  gradual  rise  of  temperature.  The 
tongue  becomes  coated  and  the  pharynx  congested;  the  epigastrium  is 


98  PRACTICE  OF  MEDICINE 

tender.  Constipation  is  the  rule.  Delirium  sometimes  occurs  at  night. 
The  fever  may  reach  103°  or  104°  F.  (39.5° — 40°  C.)  and  is  usually 
of  a  remittent  type,  occasionally  distinctly  intermittent.  The  character- 
istic curve  is  a  gradual  ascent  for  a  week  or  ten  days,  followed  by  a 
decline  of  about  the  same  duration.  A  profuse  sweat  occurs  toward 
morning,  when  the  temperature  is  low.  During  the  fever  the  joints  swell 
in  rapid  succession,  and  become  painful,  as  in  acute  rheumatism.  After 
from  one  to  three  weeks,  the  symptoms  subside  for  three  or  four  days. 
A  relapse  then  occurs;  the  former  symptoms  return,  often  with  increased 
severity.  Another  interval  occurs  after  three  or  four  weeks,  and  thus 
the  disease  progresses,  sometimes  for  several  months.  In  mild  cases, 
recovery  may  follow  the  first  relapse,  but  another  relapse  may  occur 
after  several  months.  A  malignant  form  of  the  disease  is  recognized 
which  is  usually  fatal  in  about  10  days. 

Complications  and  Sequelce. — The  chief  of  these  are  pneumonia,  neural- 
gia, and  anemia.    Orchitis  sometimes  occurs  without  other  infection. 

Diagnosis. — Typhoid  Fever. — During  the  first  rise  of  temperature,  the 
differentiation  may  be  difficult.  The"  absence  of  roseola  after  the  eighth 
day  and  failure  of  the  VVidal  test  are  important.  A  similar  agglutina- 
tion reaction  may  be  obtained  with  a  culture  of  the  micrococcus  Meliten- 
sis  and  the  serum  of  the  patient. 

Malaria  may  be  distinguished  by  the  latter  test  and  by  the  finding  of 
the  Plasmodium  in  the  blood. 

Prognosis. — The  mortality  is  about  2  per  cent.  Death  is  usually  the 
result  of  sudden  hyperpyrexia,  exhaustion,  or  complications. 

Treatment. — No  specific  treatment  has  been  discovered.  The  indi- 
cations are  in  all  respects  the  same  as  those  of  typhoid  fever. 

BERIBERI. 

KAKKI,   ENDEMIC  NEURITIS. 

This  disease  prevails  endemically  in  many  isolated  regions  of  the  tropics,  especially 
in  China,  Japan,  the  Philippine  Islands,  Hawaii,  South  America,  and  the  West  Indies. 
Cases  are  occasionally  carried  by  ship  to  the  United  States.  In  1895  a  disease  believed 
to  be  beriberi  broke  out  among  the  inmates  of  the  State  insane  as3iums  of  Ala- 
bama and  Arkansas.  It  has  appeared  also  among  the  fishermen  of  Newfoundland  and 
Cape  Cod. 

Definition. — An  acute  or  chronic  disease  of  tropical  and  subtropical 
countries  characterized  by  multiple  neuritis  with  motor  and  sensory 
disturbances,  edema,  and  visceral  lesions  of  greater  or  less  severity. 

Etiology. — Two  theories  are  maintained  in  regard  to  the  character 
of  the  disease :  First,  that  it  is  an  infection  due  to  an  unrecognized 
micro-organism;  second,  that  it  is  due  to  a  toxemia  from  food. 

1.  The  principal  argument  in  favor  of  the  theory  of  infection  is 
that  a  micrococcus  has  been  found  which,  by  inoculation,  produces 
peripheral  neuritis.  Ogata,  however,  attributes  it  to  a  bacillus.  The 
disease  occurs  at  a  definite  season  and  attacks  young,  robust  individu- 
als. It  is  a  place  disease,  clinging  to  houses  and  more  particularly  to 
isolated  localities,  as  does  malaria.  There  is  some  evidence  that  it  is 
contagious. 

2.  The  theory  of  food  toxemia  is  held  especially  in  Japan  and  Java, 


BERIBERI 


99 


where  the  disease  is  attributed  to  the  excessive  consumption  of  white 
(hulled)  rice.  It  is  said  to  have  been  repeatedly  checked  by  the  adop- 
tion of  European  food.  Visitors  to  Japan  do  not  become  aiTected  so 
long  as  they  do  not  adopt  the  rice  diet. 

The  fermentation  of  rice  is  regarded  by  several  writers  as  the  more 
direct  cause.  Capt.  E.  R.  Rost,  I. M.S.,  asserts  that  in  Rangoon,  where 
the  disease  is  epidemic,  it  is  caused  chiefly  by  drinking  rice-water  liquor 
made  by  the  Chinese  from  damaged  rice.  The  disease  is  not  seen  in 
children  there,  seldom  in  women,  and  it  is  not  infectious  or  contagious. 

Males  from  i6  to  25  are  most  frequently  attacked,  but  it  may  af- 
fect either  sex  at  any  age.  Hot,  moist  atmosphere  and  overcrowding 
favor  its  development. 

Morbid  Anaiomy. — Peripheral  neuritis  is  the  essential  lesion.  The  va- 
gus and  phrenic  arc  sometimes  involved.  Hypertrophy  of  the  right 
ventricle,  with  degeneration  of  the  myocardium,  is  usually  present.  The 
skeletal  muscles  may  be  also  degenerated. 

Symptoms. — The  incubation  probably  lasts  a  month.  The  initial 
symptoms  are  generally  catarrhal.  These  are  followed  by  pain  and 
weakness  in  the  legs,  and  paresthesia  and  edema  gradually  invading 
the  entire  body.  The  muscles  become  soft  and  sensitive.  The  heart's 
action  is  weak  and  irregular;  palpitation  may  be  felt  and  dyspnea  is 
produced.  The  urine  is  scant,  but  not  albuminous.  Recovery  may  oc- 
cur after  a  few  weeks  or  after  several  months.  Relapses  often  occur 
at  the  same  season  for  many  successive  years.  Three  forms  of  the 
disease  are  described : 

1.  Diy,  Atrophic,  or  Paretir  Form. — This  is  characterized  by  a  pain- 
ful atrophy,  with  more  or  less  complete  paralysis  of  the  muscles  of  the 
arms  and  legs,  sometimes  involving  also  those  of  the  face.  The  tendon 
reflexes  are  abolished.    Edema  is  not  usually  present. 

2.  Wet,  or  Dropsical  Form. — Edema  is  the  most  marked  feature.  The 
subcutaneous  tissue  and  serous  cavities  of  the  entire  body  are  often 
invaded.  The  degenerative  changes  in  the  muscles  may  not  be  prominent. 
Cardiac  weakness  and  dyspnea  are  seldom  absent. 

3.  Acute,  Cardiac  or  Fertiicious  Form. — Cardiac  weakness  is  the  pre- 
dominant symptom.  Death  from  heart-failure  may  take  place  within 
the  first  few  days,  before  the  development  of  other  symptoms.  V\Tien 
the  vagus  is  involved,  the  larynx  may  be  paralyzed,  and  vomiting  is 
a  prominent  symptom.  When  the  phrenic  nerve  is  affected,  death  may 
result  through  paralysis  of  the  diaphragm. 

Diagnosis. — This  is  seldom  difficult  in  tropical  regions.  The  ordi- 
nary form  of  peripheral  neuritis  does  not  involve  the  vasomotor  and  vis- 
ceral nerves,  and  it  is  not  attended  with  so  great  dyspnea  or  edema. 

Prognosis. — The  mortality  ranges  from  2  to  50  per  cent.  Much  de- 
pends upon  the  character  of  the  epidemic,  the  strength  of  the  patient, 
and  the  hygienic  conditions.  The  greatest  mortality  has  been  among 
coolies.    Vomiting  is  regarded  by  the  Japanese  as  of  fatal  import. 

Prophylaxis. — This  consists  in  proper  diet  and  hygienic  measures, 
particularly  the  prevention  of  overcrowding.  Visitors  to  localities 
where  the  disease  prevails  should  not  adopt  the  exclusively  farinaceous 
diet. 

Treatment. — The  patient  should  be  immediately  removed  to  a  high 


loo  PRACTICE  OF  MEDICINE 

and  dry  locality,  when  his  condition  will  permit.  This  is  regarded  by 
Manson  as  important  in  order  to  avoid  reinfection.  The  treatment 
should  be  begun  with  free  purgation.  Following  this  the  salicylates 
should  be  given  in  20-grain  (1.30)  doses  four  or  five  times  a  day. 
Stimulation  must  be  practiced  when  the  heart  becomes  weak.  Strychnin 
should  be  given  in  doses  of  gr.  1-40  (0.0016).  If  the  arterial  tension 
is  high,  glonoin,  gr.  i-ioo  (0.0006)  every  half-hour,  is  indicated  until 
the  heart's  action  becomes  normal.  Blood-letting  has  been  practiced 
with  benefit  in  some  cases,  and  inhalations  of  amyl  nitrite  have  been 
recommended  when  there  is  danger  of  cardiac  failure.  Nitrogenous 
food  should  constitute  the  principal  part  of  the  diet;  and  if  rice  is  eaten, 
it  should  be  the  unhulled  or  red  variety. 

SCARLET  FEVER. 

SCARLATINA,  SCARLET  RASH. 

Definiiion. — An  acute  infectious  disease  manifested  by  severe  angina 
and  an  erythematous  exanthem,  with  constitutional  symptoms  of  vari- 
able severity. 

Etiology. — The  disease  may  be  either  sporadic  or  epidemic.  It  is  ex- 
tremely contagious  and  frequently  spreads  with  great  rapidity  among 
the  inmates  of  schools  and  asylums.  -Forchheimer  has  shown  that  it 
is  probably  not  capable  of  transmission  to  any  great  distance  through 
the  atmosphere.  Mediate  contagion  is  the  rule.  No  specific  organism 
has  been  discovered.  Streptococci  and  other  germs  have  been  found  in 
the  blood,  urine,  skin,  and  in  various  organs  in  fatal  cases,  but  their 
relation  to  the  disease  has  not  been  proved.  Inoculation  has  been  suc- 
cessfully performed  with  the  blood,  serum,  nasal  and  pharyngeal  secre- 
tions. Contagion  is  generally  believed  to  take  place  directly  from  the 
patient,  through  the  exhalations,  but  by  far  the  most  dangerous  source 
of  infection  is  found  in  the  desquamated  epithelium.  Clothing,  books, 
toys,  anything  that  has  been  handled  by  the  patient,  furniture,  carpets, 
even  the  dust  from  the  sick-chamber,  retains  the  poison  and  may  con- 
vey it  to  others.  The  contagium  has  been  retained  for  several  years 
in  articles  of  clothing  protected  from  the  air,  longer  than  is  known  to 
be  possible  in  any  other  disease.  Physicians  and  nurses  have  carried 
the  infection,  and  it  is  not  infrequent  for  those  coming  into  contact 
with  the  patient  to  contract  a  severe  angina,  although  they  may  have 
had  the  disease  in  childhood.  Pets,  birds,  cats,  and  dogs,  probably  be- 
come carriers  of  the  infection  in  some  instances.  Food,  especially  milk, 
is  readily  contaminated.  Defective  house-drainage  has  been  held  re- 
sponsible for  the  disease  in  some  instances.  The  mucous  membrane 
of  the  throat  is  probably  the  usual  avenue  of  infection. 

Age. — Scarlatina  is  typically  a  disease  of  infancy  and  early  childhood. 
Half  the  cases  appear  before  the  fifth  year,  and  go  per  cent  before  the 
tenth.  Nurslings  are  seldom  attacked.  Infants,  although  born  during 
the  illness  of  the  mother,  may  escape,  but  sometimes  they  are  born  with 
the  disease.  Adults  arc  occasionally  affected.  Sex  does  not  modify  the 
susceptibility  to  it. 

Season. — Sporadic  cases  are  seen  at  all  seasons;  epidemics  generally 
prevail  during  the  autumn  and  winter. 


SCARLET  FEVER  loi 

The  immunity  conferred  by  one  attack  is  generally  permanent,  but 
second  and  third  attacks  are  not  extremely  rare.  So  far  as  known, 
the  Japanese  alone  possess  natural  immunity.  The  susceptibility  of  all 
individuals  is  not  equal,  for  it  is  not  uncommon  to  see  different  degrees 
of  severity  manifested  by  the  disease  among  the  children  of  the  same 
family,  or  for  one  or  two  members  of  a  family  to  escape.  Some  families 
are  much  more  susceptible  than  others.  The  virulence  of  the  disease 
is  much  greater  in  some  epidemics  than  in  others. 

Morbid  Anatomy. — The  cutaneous  and  pharyngeal  lesions  are  alike 
hyperemic  in  character  and  promptly  disappear  after  death,  except  in 
the  hemorrhagic  form  of  the  disease.  A  section  of  the  skin  shows  only 
capillary  dilatation,  without  the  changes  of  inflammation.  There  are 
no  characteristic  lesions;  those  found  in  the  organs  after  death  are  the 
result  of  high  temperature  or  of  pyogenic  infection.  The  serous  mem- 
branes are  more  generally  involved  than  the  mucous.  The  most  impor- 
tant complication  is  on  the  part  of  the  kidneys,  an  acute  nephritis 
being  found  in  a  large  proportion  of  fatal  cases.  As  a  result  of  the 
throat  lesions,  sometimes  pseudomembranous  in  character,  the  cervical 
lymph-glands  are  often  greatly  enlarged  and  in  a  state  of  suppuration. 
Gangrenous  sloughs  are  sometimes  found.  Lobular  pneumonia  may  be 
the  immediate  cause  of  death  in  such  cases.  The  lesions  of  endocar- 
ditis, pericarditis,  pleurisy,  and  peritonitis  are  sometimes  found.  Gastro- 
intestinal congestion  may  be  present.  The  spleen  shows  the  usual  febrile 
enlargement,  and  interstitial  changes  have  been  seen  in  the  liver. 

Symptoms. — T/ie  incubation  is  from  one  to  ten  days.  There  are  gen- 
erally no  prodromes,  but  slight  indisposition  may  be  noticed  during  the 
last  day  or  two. 

The  invasion  is  usually  sudden  and  may  be  severe.  Vomiting,  sore 
throat,  and  chilliness,  rarely  a  distinct  chill,  are  commonly  present. 
One  or  more  convulsions  may  announce  the  onset  in  young  children. 
The  patient  becomes  restless  and  delirium  may  develop  within  the  first 
24  hours.  Thirst  and  dryness  of  the  throat  are  complained  of.  The 
tongue  is  at  first  white  with  red  edges,  and  the  papillse  often  protrude 
through  the  coating,  producing  the  characteristic  "  strawberry  tongue." 
A  few  days  later,  the  fur  is  cast  off",  and  with  it  the  surface  epithelium, 
leaving  the  tongue  intensely  red  and  the  denuded  papillae  prominent, 
an  appearance  which  has  been  called  the  "  raspberry  tongue."  Leucocy- 
tosis  generally  develops  early  in  the  disease  and  may  be  extreme  in 
severe  cases. 

The  Eruption. — A  scarlet  erythema  invades  the  skin,  generally  on  the 
second  day,  sometimes  within  the  first  24  hours.  It  is  seen  first  on  the 
sides  of  the  neck,  upper  part  of  the  chest  and  back,  in  the  form  of  mi- 
nute pale  red  papules,  v/hich  rapidly  coalesce  to  form  an  intensely  scarlet 
flush,  that  spreads  within  a  few  hours  to  the  surface  of  the  entire  body. 
A  punctate  eruption  sometimes  appears  first  in  the  mucous  membrane 
of  the  mouth  and  throat.  Petechiae  are  rarely  seen,  except  in  hemor- 
rhagic cases.  Papillary  elevations  are  occasionally  noticeable,  and  minute 
yellowish  vesicles,  probably  sudamina,  sometimes  appear  (scarlatina 
miliaris).  The  face  is  livid,  except  around  the  mouth,  where  the  skin 
remains  normal,  but  appears  excessively  white  by  contrast.  The  eyelids 
become  edematous  in  severe  cases,  particularly  when  nephritis  develops. 


PRACTICE  OF  MEDICINE 


The  eruption  is  occasionally  limited  to  regions  or  appears  in  isolated 
patches.  Burning  and  itching  are  often  complained  of,  and  the  skin  may 
be  hyperesthetic.  In  malignant  cases  extreme  cellulitis  of  the  neck  is 
frequently  encountered,  and  a  false  membrane  may  develop  on  the  ton- 
sils and  spread  rapidly  to  adjacent  surfaces.  True  Klebs-Loefifier  diph- 
theria is  sometimes  present  as  a  complication.  The  eruption  begins  to 
subside,  as  a  rule,  by  the  third  day.  The  temperatu7-e  remains  high,  often 
104°  or  105°  F.  (40° — 40.5°  C),  with  slight  morning  remissions,  until 
the  fading  of  the  eruption.  Delirium  not  infrequently  persists  throughout 
the  febrile  stage,  particularly  at  night.  In  mild  cases  the  temperature 
may  not  reach  103°  F.  (39.5°  C),  but  in  the  malignant  type  it  often 
exceeds  108°  F.  (42.2°  C.)  shortly  before  death.  The  iit'ine  shows  the 
ordinary  febrile  changes,  diminution  of  quantity  with  increase  of  solids, 
particularly  the  urates.  The  frequency  of  renal  complications  renders 
daily  examination  of  the  urine  imperative. 

Desquamation  usually  begins  within  two  or  three  days  after  the  sub- 
sidence of   the    eruption,   but  may  be  delayed  for  nearly   a  week.      It 

never  fails  to  occur.  It  follows 
the  same  course  of  progression  as 
the  eruption,  beginning  on  the 
neck  and  chest.  It  may  be  fur- 
furaceous  or  membranous  in  char- 
acter, the  epidermis  separating  in 
scales  or  in  sheets.  More  or  less 
complete  molds  are  sometimes 
obtained  from  the  hands  and  feet. 
The  denuded  skin  is  for  a  time  red 
and  tender.  Desquamation  usual- 
ly lasts  from  three  to  five  weeks. 
Several  coats  are  sometimes  shed, 
and  the  progress  may  be  pro- 
tracted to  7  or  8  weeks.  The 
danger  of  communicating  the  in- 
fection does  not  end  until  the  skin 
has  become  quite  normal.  In 
rare  cases  the  hair  and  nails  are  also  cast  off.  The  itching  accompany- 
ing desquamation  is  often  intense.  The  character  of  the  desquamation 
does  not  always  conform  to  the  severity  of  the  disease,  but,  as  a  rule, 
it  is  less  extensive  in  the  milder  cases. 

Forms  of  Scarlatina. — Great  difference  is  manifested  in  the  severity 
of  symptoms.  The  disease  may  be  so  mild  as  to  readily  escape  notice 
or  to  render  the  diagnosis  difficult.  The  fever  may  not  exceed  100°  F. 
(38°  C),  and  may  last  but  a  few  hours.  The  throat  s3nTiptoms  are 
mild  and  only  a  trace  of  albumin  may  appear  in  the  urine.  Desqua- 
mation may,  however,  be  abundant.  Cases  have  been  reported  in  which 
the  eruption  was  absent  (scarlatina  sine  eruptione).  Occasionally  the 
rash  does  not  appear  until  the  fourth  or  fifth  day. 

Malignant  Scarlatina.— i.  Cases  occur  in  which  the  symptoms  of 
toxemia  predominate.  The  temperature  reaches  106°  F.  (41°  C.)  or 
higher  on  the  first  evening,  and  profound  prostration,  delirium,  and 
gastrointestinal  disturbances  are  predominant.  In  some  cases  the  fever 
continues  for  10  to  14  days  and  subsides  by  a  slow  lysis. 


FAHR. 
105.8 

104.0 
103.3 
100.4 
98.6 

C. 

41 
40 
39 
38 
37 

2 

3 

* 

5 

6 

1 

8 

9 

A 

r 

/ 

/ 

A 

1 

^ 

1 

\ 

V 

' 

\  1 

A 

y 

l\ 

K 

J 

' 

\ 

- 

- 

^ 

Y 

; 

\ 

\ 

Y 

\ 

A 

V 

\ 

f{ 

y  / 

s 

^ 

s 

\ 

, 

Fig.  9. — Temperature  chart  of  mild  scarlatina. 


SCARLET  FEVER 


103 


2.  Foudroyant  cases  are  encountered.  The  invasion  is  extremely  severe, 
with  repeated  convulsions,  immediate  rise  of  temperature  to  107°  or 
108°  F.  (41.5° — 42.0°  C),  intense  delirium,  profound  stupor  or  coma, 
and  projectile  vomiting.  The  pulse  is  feeble  and  dyspnea  urgent.  Death 
may  occur  within  the  first  24  hours,  before  the  appearance  of  the 
eruption. 

3.  A  hemorrhagic  type  is  rarely  met  with.  It  usually  terminates  fatally 
in  the  first  few  days.  Blood  is  extravasated  into  the  skin  and  mucous 
membranes,  and  there  is  bleeding  from  the  nose,  stomach,  and  bowels. 
The  temperature  may  be  moderate. 

4.  Angmose  Type. — In  this  form  the  throat  symptoms  predominate. 
A  false  membrane  usually  develops  upon  the  intensely  swollen  tonsils 
and  pharynx  and  quickly  spreads  into  the  nose  and  larynx,  often 
through  the  trachea  into  the  bronchi.  Gangrenous  sloughs  form  in  the 
throat,  and  suppurative  otitis  media  results  from  extension  of  the  in- 
ilammation  along  the  Eustachian  tube.  A  suppurative  cellulitis  of  the 
neck  follows  the  adenitis,  and  a  general  septic  infection  usually  leads 
to  a  fatal  issue,  if,  as  is  generally  the  rule,  death  has  not  occurred  earlier 
in  the  disease. 

Puerperal  and  Surgical  Scarlatina.— It  is  now  generally  believed 
that  most  of  the  cases  which  were  formerly  regarded  as  of  this  char- 
acter are  in  reality  cases  of  septicemia.  The  view  is  well  supported  by 
the  remarkable  decrease  in  the  number  of  these  cases  since  the  adoption 
of  methods  for  the  prevention  of  sepsis.  Scarlet  fever  may,  however, 
attack  the  surgical  patient  or  puerperal  woman. 

Complicaiions  and  Sequelae. — (^i')  Nephritis  is  the  most  serious  of  the 
complications.  Three  forms  occur.  They  probably  result  from  toxemia, 
although  micro-organisms  have  been  repeatedly  found  in  the  kidneys. 
They  usually  develop  during  desquamation,  in  the  second  or  third  week 
of  the  disease,  and  may  occur  in  either  mild  or  severe  cases : 

(a)  Acute  Degenerative  Nephritis. — This  is  a  mild  form  in  which  the 
lesions  are  not  inflammatory  in  character  and  are,  in  most  cases,  con- 
fined to  the  parenchyma  of  the  tubules.  It  is  indicated  by  a  reduction 
in  the  quantity  of  urine,  a  moderate  quantity  of  albumin,  a  few  hyalin, 
epithelial,  or  granular  casts.  The  constitutional  disturbances  are  slight, 
the  edema  moderate.     Recovery  is  the  rule. 

(^)  Glomerulonephritis,  or  Exudative  Nephritis. — In  this  form  the 
glomerulus,  to  which  the  involvement  is  chiefly  limited,  is  compressed 
by  an  abundant  exudation  of  serum,  red  and  white  blood-cells,  and  epi- 
thelium within  the  capsule.  The  condition  is  announced  by  an  almost 
complete  suppression  of  urine.  That  voided  contains  blood,  a  large 
quantity  of  albumin,  and  increased  urates.  The  microscope  reveals  dif- 
ferent kinds  of  casts,  blood-cells,  and  pigment.  The  constitutional  symp- 
toms are  severe  and  may  appear  early.  They  are  :  edema  of  the  face, 
hands,  and  feet,  headache,  nausea,  vomiting,  dyspnea,  muscular  twitch- 
ings,  and  sometimes  delirium.  The  fever  and  rapid  pulse  continue  with 
high  arterial  tension  and  irregular  action  of  the  heart.  The  dropsy 
may  become  extreme  and  it  may  involve  the  lungs.  Under  careful  man- 
agement, recovery  generally  occurs  in  from  four  to  six  weeks.  The  con- 
dition may  become  chronic,  however,  or  a  fatal  uremia  may  super- 
vene. 

(f)  Acute  Diffuse  Nephritis. — This  is  the  most  severe    form    of  the 


I04  PRACTICE  OF  MEDICINE 

disease,  affecting  both  parenchyma  and  interstitial  substance  of  the  glo- 
raeruH  and  tubules.  It  usually  arises  in  the  third  week,  either  suddenly 
or  gradually.  Vomiting,  marked  anemia,  and  more  or  less  complete 
suppression  of  the  urine  are  the  constant  symptoms.  Convulsions  often 
occur.  Blood  and  albumin  are  abundant  in  the  urine.  Death  usually 
occurs  early  from  uremia. 

(2)  The  Heart. — Acute  endocarditis  is  not  uncommon,  and  frequently 
leaves  permanent  lesions  of  the  valves,  often  to  be  recognized  in  after- 
life. The  malignant  form  of  endocarditis  is  rare.  Pericarditis  with 
serofibrinous  or  purulent  exudation  may  occur,  and  myocarditis  some- 
times develops. 

(3)  Serous  Membranes. — Pleurisy  is  frequent  and  may  lead  to  em- 
pyema.    Peritonitis  may  also  be  encountered. 

(4)  Nervous  System. — Chorea  and  hemiplegia  develop,  especially  in 
cases  complicated  with  arthritis  and  endocarditis,  and  are  probably  a 
result  of  embolism.  Mania  sometimes  occurs.  Progressive  paralyses 
have  been  noted.  Thrombosis  may  affect  the  lateral  sinus  or  the  cere- 
bral veins.      Meningitis  and  abscess  of  the  brain  have  been  observed. 

(5)  The  Ear. — Suppurative  otitis  media,  due  to  extension  of  the 
throat  inflammation,  is  so  frequent  and  so  severe  as  to  render  scarlatina 
one  of  the  most  common  causes  of  deafness.  The  suppuration  generally 
extends  to  the  labyrinth  and  may  involve  the  mastoid  cells. 

(6)  Suppurative  cellulitis  of  the  neck,  with  gangrenous  sloughing,  is 
an  occasional  result  of  the  throat  inflammation. 

(7)  The  Glands. — The  adenitis,  although  extreme,  usually  subsides 
in  a  few  weeks,  but  in  some  cases  it  persists  indefinitely.  Suppuration 
may  develop  and  it  may  extensively  involve  the  surrounding  tissues. 

(8)  The  Joints. — Painful  swelling  of  the  joints  sometimes  occurs  dur- 
ing the  height  of  the  fever,  but  more  frequently  during  its  decline.  It 
is  regarded  by  some  writers  as  a  form  of  rheumatism,  by  others  as  a 
septic  infection  analogous  to  gonorrheal  rheumatism.  Suppuration  some- 
times develops  in  the  affected  joints. 

(9)  Rare  Complications. — Among  these  ma}'  be  mentioned  blindness 
from  iritis  or  neuroretinitis,  S3^mmetrical  grangrene,  noma,  furunculosis, 
and  purpura  hemorrhagica.  The  association  of  scarlatina  with  other 
diseases,  notably  measles,  variola,  varicella,  and  pertussis,  is  occasionally 
observed. 

Diagnosis. — The  sudden  onset  with  vomiting,  rapid  rise  of  temperature, 
the  angina  with  enlargement  of  the  cervical  glands,  the  early  appear- 
ance of  the  eruption,  and  the  strawberry  tongue  seldom  leave  the  di- 
agnosis long  in  doubt.  Cases  arise,  however,  in  which  much  difficulty 
is  experienced. 

1.  Acute  Exfoliative  Dermatitis. — This  affection  closely  simulates  scar- 
latina in  its  sudden  febrile  onset  and  uniform  red  rash.  The  throat 
symptoms  are  usually  absent,  the  tongue  is  not  typical,  the  eruption 
appears  first  on  the  trunk  and  has  not  faded  away  until  desquamation 
has  begun.  The  hair  and  nails  are  usually  involved  in  the  exfoliation. 
Repeated  attacks  are  common,  even  within  short  intervals  of  time, 
a  fact  which  doubtless  explains  many  instances  of  supposed  recurrent 
attacks  of  scarlatina. 

2.  Measles.~~\xv  this  disease  we  have  prodromal  catarrh,  a  less  violent 


SCARLET  FEVER  105 

invasion,  subsidence  of  temperature  before  the  appearance  of  the  erup- 
tion on  the  third  or  fourth  day.  The  eruption  is  papular,  more  abun- 
dant on  the  face,  and  often  shows  crescentic  arrangement.  The  throat 
symptoms  are  mild  or  absent  and  the  leucocytes  are  not  increased. 

3.  Rotheln. — This  disease  is  usually  excluded  by  the  mild  invasion, 
slight  febrile  disturbance,  and  the  paleness  and  mottled  character  of  the 
rash,  which  appears  first  on  the  face. 

4.  Diphtheria. — In  most  cases  the  absence  of  the  Klebs-Ldfifler  bacillus 
is  sufficient  to  distinguish  scalatina  with  membranous  throat  formation 
from  true  diphtheria.  When,  however,  this  bacillus  is  present,  it  is  often 
difficult  to  decide  whether  the  case  is  one  of  diphtheria  with  erythematous 
eruption  or  a  double  infection.  The  diphtheria  rash  is  usually  dark  red 
and  confined  to  the  trunk. 

5.  Septicemia. — The  more  uniform  and  prolonged  febrile  course  of  this 
condition  may  suffice  for  differentiation.  It  is  not  always  possible  to 
distinguish  the  two  affections  in  the  puerperal  period. 

6.  Drug  Rashes. — Belladonna  and  quinin,  less  frequently  potassium 
bromid  and  iodid,  chloral,  acetanilid,  and  other  drugs  produce  rashes 
resembling  that  of  scarlet  fever.    The  other  symptoms  are  lacking. 

Prognosis. — The  disease  is  most  fatal  in  young  children  and  among 
the  poor.  Some  epidemics  are  much  more  fatal  than  others.  High 
fever,  delirium,  membranous  angina,  and  hemorrhages  are  exceedingly 
unfavorable  symptoms.  Even  in  the  mildest  cases  a  serious  nephritis 
may  develop  at  a  time  when  recovery  seems  certain.  Nephritis  is  not 
necessarily  a  fatal  complication;  most  cases  recover.  The  total  mor- 
tality of  the  disease  ranges  from  5  to  i  o  per  cent  in  the  milder  epidemics 
and  from  20  to  30  in  the  more  severe. 

Prophylaxis. — The  patient  should  be  isolated  and  the  house  quar- 
antined. The  other  children  of  the  family  should  be  kept  from  school 
and  prevented  from  associating  with  their  playmates  long  enough  to 
determine  that  they  have  not  also  contracted  the  disease.  The  same 
precautions  should  be  taken  with  reference  to  the  apartments  and  the 
conduct  of  the  physician  and  nurse  as  are  recommended  under  the 
prophylaxis  of  smallpox.  The  patient  need  not  be  confined  to  bed 
longer  than  a  week  or  ten  days  after  the  fever  has  subsided,  in  the 
absence  of  other  contraindications ;  but  care  should  be  exercised  to  avoid 
exposure  to  cold  for  three  or  four  weeks  longer.  The  quarantine  should 
last  six,  or,  better,  eight  weeks,  or  in  any  case  until  the  last  indication' 
of  desquamation  has  disappeared. 

Treatment. — The  room  should  be  well  ventilated,  and  a  uniform  tem- 
perature of  68°  F.  (20°  C.)  should  be  maintained.  The  patient  should 
wear  a  flannel  gown,  but  the  bedclothing  should  be  light.  The  diet 
should  be  liquid  during  the  febrile  stage,  preferably  milk,  in  addition 
to  which  gruels,  broths,  and  tgg  albumen  may  be  allowed.  Ice  cream  is 
nourishing  and  soothing  to  the  throat.  An  abundance  of  water  should 
be  given.  Solid  food  may  be  allowed  after  the  fever  has  subsided  in 
a  mild  case,  but  a  continuance  of  the  milk  diet  reduces  the  Hability 
to  nephritis.  Medication  is  unnecessary  in  mild  cases.  An  antiseptic, 
as  sodium  sulphocarbolate  or  salicylate,  should  be  given  with  a  view  to 
reducing  the  liability  to  complications.  For  high  temperature,  restless- 
ness,  or  delirium  the  bath  of  90°  F.  (32°  C),  gradually  reduced,  cool 


io6  PRACTICE  OF  MEDICINE 

sponging,  or  the  wet  pack  should  be  employed,  and  the  bromids  may  be 
administered.  The  ice-cap  is  often  useful.  The  bowels  should  be  regu- 
lated with  magnesium  citrate,  compound  licorice  powder,  or  other  aperi- 
ent. The  action  of  the  kidneys  must  be  favored  by  a  plentiful  supply 
of  pure  cold  water,  lemonade,  or  other  drink.  Irrigation  of  the  bowel 
every  six  or  eight  hours  with  a  pint  or  more  of  water  at  iio°  F.  (43°  C.) 
is  recommended  for  the  restoration  of  the  renal  secretion  and  for  the 
relief  of  convulsions. 

The  throat,  nose,  ears,  heart,  and  urine  should  be  examined  daily, 
and  the  examinations  of  the  urine  should  be  continued  periodically  dur- 
ing convalescence.  For  weak  heart,  stimulants  should  be  given.  Peri- 
carditis requires  special  treatment  described  under  that  disease.  For 
the  throat  and  nose,  a  spray  of  5  per  cent  menthol  and  camphor  in 
liquid  albolin  or  10  per  cent  hydrozon  is  beneficial.  Otitis  requires 
puncture  of  the  drum  membrane  as  soon  as  tension  becomes  prominent. 
Renal  complications  are  to  be  treated  according  to  the  methods  given 
under  Nephritis. 

As  soon  as  desquamation  has  commenced,  the  patient  should  be 
given  a  warm  bath  morning  and  evening,  followed  by  thorough  in- 
unction of  the  entire  body  with  sweet  oil  or  carbolated  vaselin  in  order 
to  limit  the  dissemination  of  the  scales. 


MEASLES. 

RUBEOLA,   MORBILLI. 

Definition. — An  acute  infectious  disease  running  a  febrile  course  and 
exhibiting  a  papulomacular  exanthem. 

Eiiology. — The  bacterial  cause  of  the  disease  is  unknown.  Measles 
is  the  most  infectious  of  the  exanthemata,  and  immunity  is  exceedingly 
rare.  It  is  highly  contagious  during  its  entire  course,  including  the 
last  days  of  the  incubation.  It  occurs  endemically  in  cities  at  all  sea- 
sons, and  epidemically  about  every  second  winter.  Age  has  probably 
little  influence  on  susceptibility,  but  few  persons  escape  the  disease  dur- 
ing their  childhood.  Infants  under  six  months  are  seldom  attacked. 
The  disease  is  by  no  means  infrequent  in  adults.  Second,  third,  and  even 
fourth  attacks  have  occasionally  been  reported.  The  contagium  is  com- 
municated by  the  breath  and  secretions  of  the  patient,  particularly  by 
the  nasal  mucus,  saliva,  and  tears.  It  may  be  carried  by  a  third  person, 
by  fomites,  or  by  the  air,  but  the  poison  is  not  so  virulent  or  so  reten- 
tive of  life  as  that  of  scarlatina.    Inoculation  has  been  performed. 

Morbid  Anatomy. — The  lesions  of  the  mucous  membranes  are  the  same 
as  those  of  other  catarrhal  conditions.  The  mortality  is  due  chiefly  to 
complications,  especially  to  bronchopneumonia.  The  bronchial  glands 
are  always  enlarged.  The  gastrointestinal  mucous  membrane  is  fre- 
quently hyperemic  and  the  solitary  and  agminated  follicles  are  often 
greatly  enlarged.  Leucocytosis  is  absent.  Demme  found  during  the 
height  of  the  fever  a  diminution  of  the  red  blood-corpuscles,  numerous 
microcytes  and  free  nuclei,  and  a  diminution  in  the  quantity  of  fibrin  in 
the  blood. 


MEASLES 


107 


Symptoms. — The  period  of  incubation  generally  lasts  from  7  to  14 
days.  Fretfulness  and  slight  fever  may  be  noticed  during  this  time. 
The  invasion  is  often  announced  by  chilly  sensations,  occasionally  by 
vomiting;  rigors  and  convulsions  are  rare.  The  first  symptoms  are 
usually  those  of  coryza,  generally  accompanied  by  hyperemia  of  the 
pharynx  and  larynx  and  conjunctival  congestion,  with  lachrymation  and 
photophobia.  Sneezing,  cough,  and  hoarseness  develop  and  the  child 
becomes  fretful  and  cross.  The  tongue  is  furred;  the  edges  may  remain 
red  and  the  papillae  prominent. 

The  temperature  may  rise  abruptly  on  the  first  day  to  103°  or  104° 
F.  (39.5 — 40.0°  C),  but  it  sometimes  pursues  a  more  gradual  elevation 
until  the  appearance  of  the  eruption.  Nausea  and  vomiting  are  occa- 
sionally persistent.  In  mild  cases  the  symptoms  of  invasion  may  be  so 
trifling  as  to  escape  observation. 

KopUk''s  Spots. — Peculiar  spots,  first  described  by  Koplik,  can  be  seen 
on  the  mucous  membrane  of  the 
lips  and  cheeks  with  the  aid  of 
strong  daylight,  in  most  cases  24 
to  48  hours,  sometimes  four  or 
five  days,  before  the  appearance 
of  the  eruption.  They  are  small, 
bright  red  spots,  each  of  which 
shows  in  its  center  a  minute, 
bluish  white  speck.  The  speck 
can  be  picked  off  with  a  forceps 
or  removed  by  rubbing.  The 
spots  coalesce,  and,  when  fully 
developed,  the  labial  and  buccal 
mucous  membranes  appear  uni- 
formly rose-red,  with  a  studding 
of  myriads  of  bluish  white  specks. 

Stage  of  Eruption. — On  the  evening  of  the  third  day  the  child  gen- 
erally appears  more  fretful  and  its  sleep  is  more  restless.  The  morning 
of  the  fourth  day,  the  eruption  can  generally  be  detected  upon  the  face, 
and  it  becomes  distinctly  visible  during  the  day.  It  appears  first  on 
the  forehead,  chin,  and  sides  of  the  neck,  in  the  form  of  slightly  elevated, 
round  or  lenticular  papules  of  variable  size.  The  papules  enlarge  and 
are  often  so  numerous  on  the  face  as  to  cover  its  entire  surface  with 
dark  red  blotches  which  can  often  be  distinctly  felt  with  the  finger. 
On  the  chest,  arms,  and  back  they  usually  coalesce  into  crescentic  figures. 
Petechiae  are  sometimes  seen,  especially  in  the  more  malignant  cases, 
and  miliary  vesicles  are  sometimes  observed.  From  the  face  and  neck 
the  eruption  gradually  invades  the  entire  surface  of  the  body,  reaching 
the  lower  extremities  by  the  evening  of  the  fifth  or  sixth  day  of  the 
disease.  It  remains  two  or  three  days  in  each  locality,  then  rapidly 
fades.  A  fine,  bran-like,  furfuraceous  desquamation,  often  scarcely  notice- 
able, follows  its  disappearance.  The  mucous  membranes  of  the  mouth, 
throat,  and  larynx  are  often  invaded  by  the  eruption. 

With  the  appearance  of  the  exanthem,  the  catarrhal  symptoms  be- 
come aggravated  and  the  bronchial  mucous  membrane  becomes  involved. 
The  temperature  often  reaches  105°  or  106°  F.  (40.5° — 41.0°  C.)  on  the 


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Fig.  10. — Temperature  chart  of  measles. 


io8  PRACTICE  OF  MEDICINE 

evening  of  the  fourth  day;  the  pulse  is  rapid,  120  to  150,  and  bounding. 
Epistaxis  sometimes  occurs.  The  cough  is  often  distressing.  The  rest- 
lessness is  greatly  added  to  in  some  cases  by  persistent  vomiting,  thirst, 
irritability  of  the  bladder,  diarrhea,  intense  burning  of  the  skin,  and 
insomnia.    Delirium  develops  in  severe  cases. 

There  is  more  or  less  general,  though  moderate,  enlargement  of  the 
lymphatic  glands.  The  urine  frequently  contains  albumin,  pepton,  and 
aceton  and  gives  the  diazo  reaction.  All  the  symptoms  promptly  sub- 
side as  the  eruption  fades,  with  the  exception  of  those  due  to  the  bron- 
chial catarrh,  which  frequently  persists. 

Atypical  Cases.— (i)  In  epidemics,  it  is  not  unusual  to  meet  with 
cases  in  which  the  eruption  appears  on  the  second  or  third  day,  and 
others  in  which  it  is  delayed  as  long  as  the  sixth  day  or  later, 

(2)  Cases  occur  in  which  the  catarrhal  symptoms  are  prominent, 
but  the  eruption  absent,  and  others  in  which  the  eruption  appears 
without  the  usual  catarrh. 

(3)  Hemorrhagic  or  Black  Measles.— This  form  of  the  disease  is 
characterized  by  hemorrhages  into  the  skin  and  mucous  membranes, 
great  prostration,  hyperpyrexia,  and  violent  delirium  or  profound  stupor. 
It  is  encountered  especially  in  prisons  and  asylums  or  among  the  ab- 
origines of  a  country  in  which  the  disease  has  not  previously  prevailed. 
The  mortality  may  exceed  25  per  cent. 

(4)  Malignant  cases  occur  with  the  same  symptoms  of  profound 
intoxication  as  in  black  measles,  but  without  the  hemorrhages.  Death 
may  occur  before  the  appearance  of  the  eruption. 

Complications  and  ^e^t/e/ce.— Bronchopneumonia  is  a  frequent  and 
often  fatal  complication,  particularly  in  debilitated  children  and  amid 
bad  hygienic  surroundings.  The  enlarged  bronchial  glands  often  become 
tubercular  and  may  thus  become  the  nidus  for  the  development  of  acute 
miliary  tuberculosis.  Although  the  laryngeal  catarrh  is  often  severe, 
edema  seldom  develops.  A  fatal  pseudomembranous  growth  sometimes, 
spreads  over  the  pharynx  and  larynx.  In  some  cases  it  is  due  to  diph- 
theritic infection.  Corneal  ulcers  and  blepharitis  not  infrequently  occur 
and  optic  neuritis  may  develop.  Otitis  is  sometimes  a  sequel.  Noma 
of  the  cheek  or  vulva  often  owes  its  origin  to  this  disease.  Entero- 
colitis, with  profuse  diarrhea,  is  an  occasional  complication.  Diphtheria^ 
whooping  cough,  and  other  affections  are  occasionally  associated  with 
the  disease.  Tuberculosis  is  the  most  serious  of  the  possible  sequelae. 
Such  affections  as  paralysis,  generally  due  to  neuritis  or  myelitis,  pleurisy,, 
pericarditis,  nephritis,  and  arthritis  are  seldom  seen. 

Diagnosis. — Measles  is  generally  differentiated  by  the  character  of 
the  prodromal  symptoms,  particularly  the  cough,  sneezing,  congestion 
and  suffusion  of  the  eyes,  and  the  presence  of  Kophk's  spots.  A  febrile 
period  of  four  days  associated  with  these  symptoms  and  followed  by 
a  papular  eruption  on  the  face  serves  to  distinguish  it  from  other 
aff"ections. 

Scarlatina  is  much  more  acute  in  its  onset;  the  diffuse  eruption  ap- 
pears on  the  second  day,  and  the  strawberry  tongue  is  characteristic. 

Rothehi  is  distinguished  by  the  mildness  of  the  invasion,  brighter  color 
of  the  efflorescence,  the  absence  of  crescentic  figures,  and  the  greater 
enlargement  of  the  cervical  lymph  glands.     Copaiba,  quinin,  and  anti- 


GERMAN  MEASLES  109 

pyrin  occasionally  produce  rashes  resembling  measles,  but  the  fever  and 
catarrhal  symptoms  are  absent. 

Treatment. — As  prophylactic  measures  the  patient  should  be  isolated 
for  two  weeks  from  the  onset.  After  recovery,  he  should  receive  an 
antiseptic  bath;  the  clothing  and  bed-linen  should  be  thoroughly  dis- 
infected by  boiling,  and  the  room  with  formaldehyd  vapor. 

In  a  mild  case  confinement  to  bed  and  daily  sponging  are  often  all 
that  are  necessary.  The  room  should  be  well  ventilated,  moderately  dark, 
and  of  uniform  temperature.  The  diet  should  be  liquid  during  the  height 
of  the  fever.  Medication  is  often  necessary.  The  restlessness,  insomnia, 
and  delirium,  when  present,  call  for  the  administration  of  the  bromids 
and  cool  baths.  The  cough  should  be  kept  under  control  by  a  mixture 
of  camphorated  tincture  of  opium  and  ipecacuanha,  squill,  or  ammonium 
chlorid.  The  danger  of  the  tubercular  infection  requires  that  the  treat- 
ment be  continued  until  recovery  is  complete  and  the  cough  has  entirely 
ceased.  The  eyes  should  be  cleansed  several  times  a  day  with  a  2 
per  .  cent  boric  acid  solution,  and  a  little  pure  vaselin  should  be  ap- 
plied to  the  edges  of  the  lids.  The  throat  and  ear  should  be  occasion- 
ally examined  and  antiseptic  sprays  used  when  indicated.  If  otitis 
develops  the  membrane  must  be  promptly  incised.  During  desquamation 
the  skin  should  be  anointed  once  a  day  after  bathing,  with  oil  or 
vaselin. 

GERMAN  MEASLES. 

RUBELLA,   ROTHELN,   RUBEOLA  NOTHA. 

Definition . — An  acute  infectious  disease  of  mild  type,  characterized 
by  a  macular  cutaneous  eruption  and  enlargement  of  the  cervical  lymph- 
glands. 

Etiology. — Rotheln  is  a  highly  contagious  disease,  prevailing  mostly 
in  the  winter  and  spring  months,  among  children,  and  often  assum- 
ing epidemic  proportions.  Old  age  is  not  exempt,  and  congenital 
cases  have  been  observed.  It  is  entirely  distinct  from  measles  and  scar- 
let fever.  One  attack  usually  confers  immunity.  The  specific  cause  is 
unknown. 

Symptoms. — Incubation  lasts  from  10  to  20  days.  The  invasion  is 
like  that  of  a  very  mild  case  of  measles,  with  slight  headache,  coryza, 
sore  throat,  pain  in  the  back  and  extremities,  chilliness  in  some  cases, 
and  an  elevation  of  temperature  seldom  reaching  102°  F.  (39.0°  C). 
The  cervical  lymph-glands  are  distinctly  enlarged,  sometimes  for  sev- 
eral days  before  the  development  of  other  symptoms.  The  eruption 
appears  on  the  first  or  second  day,  sometimes,  it  is  stated,  as  late  as 
the  third.  It  comes  out  first  on  the  face  and  palate,  then  on  the  chest, 
and  extends  within  24  hours  to  the  entire  surface  of  the  body,  including 
the  palms  and  soles.  Cases  have  been  reported  in  which  the  rash  was 
confined  to  limited  areas.  In  character  it  may  be  macular  or  papular, 
slightly  elevated,  round,  rose-colored  spots,  distinct  except  on  the  but- 
tocks and  inner  sides  of  the  thighs,  where  the  maculae  frequently  coalesce. 
The  spots  vary  in  size  as  do  those  of  measles,  but  are  often  larger. 
The  efflorescence  is  brighter  than  that  of  measles  and  does  not  usually 


no  PRACTICE  OF  MEDICINE 

form  crescents.  The  intervening  skin  is  often  hyperemic,  without  the 
punctate  appearance  of  scarlatina.  A  few  small  vesicles  or  pustules 
have  been  observed  in  connection  with  the  rash.  Itching  is  sometimes 
present.  The  eruption  begins  to  fade  in  two  or  three  days.  The  disease 
runs  its  course  in  about  live  or  six  days.  It  is  followed  by  a  fine,  flaky 
desquamation.  Slightly  pigmented  spots  are  frequently  left.  Sometimes 
it  is  more  severe,  resembling  measles  except  in  the  character  of  the 
eruption.    Albuminuria  has  been  noted  in  some  instances. 

Diagnosis. — The  disease  is  to  be  differentiated  chiefly  from  measles 
and  scarlet  fever;  erythema  and  urticaria  may  enter  into  the  consider- 
ation. 

Measles.— T\\G  eruption  is  paler,  less  elevated,  and  appears  earlier 
than  that  of  measles  and  does  not  form  crescentic  figures.  The  symp- 
toms are  in  every  respect  milder. 

Scarlatina. — The  spotty  character  of  the  eruption,  appearing  first  on 
the  face,  the  less  intensity  of  the  throat  symptoms,  the  slower,  milder 
invasion  without  vomiting,  and  the  absence  of  the  strawberry  tongue 
generally  distinguish  it  from  scarlatina.  In  the  absence  of  an  epidemic 
it  may  be  extremely  difficult  to  distinguish  a  severe  case  from  a  mild 
attack  of  either  measles  or  scarlatina. 

Erythema  appears  for  the  most  part  on  the  hands  and  feet,  is  gener- 
ally accompanied  by  burning  pain,  and  is  not  attended  with  coryza. 

Urticaria  is  characterized  by  the  appearance  of  "wheels,"  with  intense 
itching,  chiefly  on  the  extremities.    There  is  no  coryza. 

Treatmeni. — The  treatment  is  that  of  a  miild  case  of  measles.  In 
most  cases  medication  is  superfluous;  it  is  generally  difficult  to  confine 
the  patient  to  the  house. 

RUBELLA  SCARLATINOSA. 

The  provisional  name  of  "Fourth  Disease"  was  given  by  Dukes,  of 
England,  in  1900,  to  a  train  of  symptoms  which  he  regards  as  belong- 
ing to  a  distinct  infection  not  heretofore  differentiated  from  scarlatina 
and  rubella.  He  studied  it  in  19  cases  in  the  school  at  Rugby.  A  more 
extensive  study  is  that  of  Curtis  and  Shaw,  of  Albany,  in  1902,  compris- 
ing 147  cases,  of  whom  81  were  adults. 

Symptoms. — Incubation  lasts  about  19  days.  During  this  stage  the 
malaise  is  so  slight  as  to  readily  escape  observation.  Vomiting  does 
not  occur.  The  eruption  is  generally  the  first  symptom  to  attract  at- 
tention. It  envelops  the  entire  body  in  a  diffuse  erythema  without  the 
punctate  features  of  scarlatina.  Pressure  causes  only  the  most  transient 
blanching.  The  throat  is  red  and  swollen,  and  an  exudate  sometimes 
forms  on  the  tonsils,  but  in  many  cases  it  occasions  little  discomfort. 
The  Klebs-Loffler  bacillus  is  not  found.  The  tongue  is  furred  throughout, 
but  "cleans  as  all  furred  tongues  do."  Desquamation  sometimes  lasts 
six  or  seven  weeks.  In  some  cases  the  skin  becomes  merely  rough,  while 
in  others  the  epidermis  comes  off  in  strips  or  lamellae  as  extensive  as 
any  seen  in  scarlet  fever.  It  bears  no  relation  to  the  intensity  of  the 
eruption.  The  lymph-glands  are  uniformly  enlarged,  hard,  and  tender, 
but  less  so  than  in  rotheln.  The  temperature  is  moderate,  averaging 
101°  F.    (38.3°  C),  and  usually  subsides  on  the  third  or  fourth  day. 


CEREBROSPINAL  MENINGITIS  in 

The  pulse  ranges  from  loo  to  120.  Albuminuria  is  absent.  Treat- 
ment is  not  usually  required.  There  is  much  doubt  as  to  the  pro- 
priety of  admitting  the  disease  as  an  entity  and  not  merely  as  a  form 
of  rubella. 

CEREBROSPINAL    MENINGITIS. 

CEREBROSPINAL  FEVER,  SPOTTED  FEVER,   EPIDEMIC  LEPTOMENINGITIS. 

Definition. — A  severe  infectious  fever  caused  by  the  diplococcus  in- 
tracellularis  meningitidis,  occurring  epidemically  or  sporadically  and  char- 
acterized by  an  inflammation  of  the  cerebrospinal  meninges  and  a  great 
diversity  of  clinical  manifestations. 

Etiology. — The  diplococcus  intracellularis  meningitidis  is  recognized  as 
the  specific  cause  of  the  disease.  It  resembles  the  gonococcus  in  form, 
but  not  in  its  behavior  on  culture  media.  It  is  found  chiefly  in  the 
polynuclear  leucocytes,  both  in  the  tissues  and  in  the  cerebro-spinal 
fluid,  sometimes  in  the  fluids  of  the  joints.  From  the  fact  that  it 
is  found  in  the  secretions  of  the  nose,  Striimpell  and  Weigert  be- 
lieve that  infection  takes  place  through  this  channel,  and  it  has  been 
suggested  that  the  meninges  are  reached  by  way  of  the  Eustachian 
tube  and  ear.  Weichselbaum  calls  attention  to  the  possibility  of  its 
occurring  through  the  auditory  canal.  Its  transmission  from  place 
to  place  is  not  understood.  The  frequent  occurrence  of  the  disease 
among  soldiers  in  crowded  barracks  and  among  prisoners  suggests  con- 
tagion, but  is  probably  due  rather  to  unhygienic  surroundings,  for  it 
often  occurs  sporadically  in  populous  tenements,  and  epidemics  have  been 
more  frequent  in  rural  districts  than  in  the  cities.  It  occurs  most  fre- 
quently in  children  and  young  adults,  but  no  age  is  exempt.  Over- 
exertion, lack  of  ventilation,  uncleanliness,  and  crowding  are  impor- 
tant predisposing  influences.  A  second  attack  has  been  reported  in  five 
instances  (Councilman). 

Morbid  Anatomy. — In  the  early  fatal  cases  death  is  probably  due  to 
the  intense  action  of  the  toxin.  No  lesions  are  usually  found  beyond 
intense  hyperemia  of  the  meninges.  In  less  rapidly  fatal  cases,  a  fibrino- 
plastic  exudation  is  found,  especially  at  the  base  of  the  brain  and  along 
the  fissures  and  sulci  of  the  cortex ;  the  pia  is  opaque.  The  membranes  at 
the  base  may  be  much  thickened.  In  more  protracted  cases  there  is  still 
more  marked  thickening  of  the  meninges,  the  ventricles  are  distended 
with  a  fibrinopurulent  fluid,  a  fluid  consisting  of  serum,  fibrin,  pus-cells, 
and  diplococci.  The  posterior  cornua  often  contain  pure  pus.  The  brain 
substance  is  softened  and  has  a  pinkish  tinge;  areas  of  encephalitis 
and  hemorrhagic  foci  are  frequently  found.  The  cranial  nerves,  especially 
the  second,  fifth,  seventh,  and  eighth,  are  frequently  involved,  and  the 
spinal  nerve  roots  are  embedded  in  the  exudate  and  their  axis  cylinders 
are  swollen.  A  chronic  hydrocephalus  is  sometimes  developed,  particu- 
larly in  children.  Congestion,  with  granular  and  fatty  degeneration  of 
the  heart,  liver,  or  kidneys  and  other  organs,  is  often  found.  The  spleen 
is  enlarged  and  soft.  Hemorrhages  may  be  found  in  the  skin,  serous 
membranes,  particularly  the  pleura  and  pericardium,  or  in  the  viscera. 
Congestion  or  edema  of  the  lungs  and  bronchopneumonia  occur,  and  a 
lobar  pneumonia,  due  either  to  the  pneumococcus  or    the    diplococcus 


112  PRACTICE  OF  MEDICINE 

intracellularis,  is  by  no  means  infrequent.  The  larger  joints  often  become 
distended  with  a  seropurulent  exudate,  and  the  muscles  show  granular 
or  fatty  degeneration. 

Symptoms. — The  incubation  period,  probably  lasting  a  week  or  ten 
days,  is  not  usually  accompanied  by  prodromal  symptoms.  Headache, 
pain  in  the  back,  loss  of  appetite,  and  slight  nasal  catarrh  are  sometimes 
observed.  The  onset  is  generally  abrupt,  with  intense  headache,  a  chill 
or  convulsions,  rise  of  temperature  to  102°  or  103°  F.  (39.0° — 39.5° 
C),  and  projectile  vomiting.  The  muscles  of  the  neck  and  spine  soon 
become  sensitive,  painful,  and  rigid,  the  pain  and  rigidity  often  extend- 
ing also  to  the  muscles  of  the  extremities.  In  extreme  cases  the  head 
is  drawn  far  back  and  in  some  cases  the  entire  spine  is  bowed  (opisthot- 
onos). Motion  of  the  head  is  painful  or  may  be  impossible,  on  account 
of  the  rigidity.  Unconsciousness  or  delirium  early  supervenes.  Photo- 
phobia, sluggish  reaction  or  unequal  dilatation  of  the  pupils,  are  com- 
monly observed,  and  strabismus,  nystagmus,  or  ptosis,  with  conjunc- 
tivitis, is  not  infrequently  present.  Hypersensitiveness  to  sound  is 
observed  in  almost  all  cases,  and  swallowing  is  often  painful.  The  face 
has  a  drawn  appearance  expressive  of  pain.  The  temperature  range  is 
exceedingly  variable,  sometimes  rising  suddenly  to  104°  or  105°  F.  (40° 
— 40.5°  C),  and  then  declining  nearly  or  quite  to  the  normal,  only  to  rise 
again,  without  apparent  cause  for  the  fluctuation.  A  fatal  termination  is 
generally  preceded  by  a  sudden  rise,  perhaps  to  110°  F.  (43.3°  C.),or  by 
a  decline  to  a  subnormal  degree.  The  pulse  may  be  rapid  or  slow.  Respi- 
ration is  usually  accelerated.  Slow  respiration,  with  dyspnea,  due  to  pres- 
sure on  the  respiratory  centers,  is  sometimes  noted  in  a  late  stage  of 
the  disease.  A  sighing  or  a  Cheyne-Stokes  respiration  is  sometimes  ob- 
served. 

The  nervous  manifestations  are  usually  prominent  features  of  the  case. 
After  the  first  delirium  the  patient  may  arouse  with  apparent  promise 
of  improvement,  but  the  delirium  soon  returns  and  often  becomes  mani- 
acal. It  usually  gives  place  in  a  few  days  to  a  stupor,  which  may  deepen 
into  coma.  The  face  is  usually  dull  and  expressionless,  except  at  ir- 
regular intervals,  when  it  is  drawn  into  a  distressing  grimace,  and  the 
patient,  if  a  child,  utters  a  shrill,  piercing,  characteristic  cry  (the  hydro- 
cephalic cry).  A  spasm  of  the  muscles  is  not  infrequent,  when  the  fea- 
tures remain  constantly  drawn  into  a  peculiarly  ghastly  grin  (the  risus 
sardonicus).  Twitching  is  frequently  observed  in  the  muscles  of  the 
extremities ;  the  forearms  are  flexed  upon  the  chest,  and  the  thighs  and 
legs  are  flexed  in  many  cases  and  often  rotated  to  one  side.  Later  the 
limbs  may  become  fixed  in  these  positions. 

Herpes  of  the  lips  is  seen  in  about  half  the  cases;  petechige  or  pur- 
puric spots  sometimes  occur,  especially  in  malignant  cases,  general  pur- 
pura is  seldom  encountered,  although  it  gave  the  name  "  spotted  fever" 
to  the  disease.  Dusky  erythematous  spots  are  occasionally  seen  over 
the  course  of  the  peripheral  nerves.  Rose-spots  like  those  of  typhoid 
fever  have  been  observed,  and  urticaria,  ecthyma,  pemphigus,  and  very 
rarely  gangrene  of  the  skin  have  been  recorded. 

The  vomiting  generally  subsides  after  the  first  day  or  two,  but  it  is 
sometimes  a  distressing  symptom  throughout  the  disease.  Diarrhea 
occurs  in  some  cases;  constipation  is  a  more  general  condition.      The 


CEREBROSPINAL  MENINGITIS  113 

urine  sometimes  contains  albumin,  less  frequently  sugar;  hematuria 
is  a  frequent  feature  of  malignant  cases. 

Lumbar  puncture  shows  an  increase  of  pressure  within  the  spinal  ca- 
nal, and  the  fluid  obtained  is  turbid,  often  purulent,  and  when  examined 
microscopically  reveals  polynuclear  leucocytes  and  numerous  diplococci. 
Leucocytosis  is  usually,  but  not  invariably,  observed  in  the  blood-count. 

Varieties  of  the  Disease. — The  types  of  the  disease  generally  recog- 
nized are  the  following : 

1.  The  ordinary  form  that  has  been  described. 

2.  Unusually  mild  cases,  in  which  headache,  vertigo,  vomiting,  and 
moderate  fever  are  observed,  possibly  hyperesthesia  and  stiffness  of  the 
extremities,  but  the  disease  pursues  a  moderate  course  and  recovery  is 
usually  complete. 

3.  Abortive  cases  in  which  the  onset  is  sudden  and  often  severe,  but  the 
symptoms  rapidly  subside,  sometimes  with  profuse  sweating  or  epistaxis, 
as  if  by  crisis.     Convalescence  is  established  often  within  the  first  week. 

4.  A  malignant  form  in  which  the  nervous  manifestations  are  of 
extreme  severity,  although  the  temperature  may  not  be  high.  The  pulse 
is  often  below  60  and  feeble.  A  purpuric  eruption  is  usuallj^^  observed. 
Death  often  occurs  within  24  hours. 

5.  An  hitermittent  type  is  recognized,  in  v/hich  the  temperature  pur- 
sues a  course  more  characteristic  of  pyemia,  rising  more  or  less  abruptly 
every  day  or  every  second  day,  falling  nearly  or  quite  to  the  normal 
in  the  interval  of  remission. 

6.  A  chro7iic  form,  which  often  lasts  five  or  six  months,  to  be  followed 
even  then  by  incomplete  recovery  or  a  fatal  issue.  A  condition  of  ex- 
treme emaciation  (marasmus)  and  various  sensory  and  psychical  dis- 
turbances, with  contractures  of  the  limbs,  is  generally  produced.  The 
protracted  course  of  the  disease  is  marked  by  occasional  recurrences  of 
fever  and  other  symptoms.  Osier  looks  upon  these  protracted  cases  as 
probably  due  to  chronic  hydrocephalus  or  abscesses  of  the  brain. 

Complications  and  SequeloB. — Lobar  and  bronchopneumonia,  pleurisy, 
endocarditis,  and  pericarditis  are  not  infrequent  complications.  Per- 
sistent headache,  and  various  affections  of  the  eye  or  ear  resulting  in 
blindness  or  deafness,  are  only  too  commonly  encountered.  Deaf-mutism, 
aphasia,  chronic  hydrocephalus,  imbecility,  and  various  paralyses  fre- 
quently remain.  Arthritis  of  variable  severity  is  almost  always  present. 
In  the  worst  cases  the  exudation  into  the  joint  becomes  purulent,  and  per- 
manent contractures  and  deformities  result.  Even  after  convalescence 
has  progressed  favorably  for  weeks  there  is  no  assurance  of  ultimate 
complete  recovery.  Emaciation,  anemia,  feeble  digestion,  and  general 
debility  often  remain  for  months. 

Diagnosis. — The  sudden  invasion  with  chill,  the  intense  headache, 
pains  in  the  neck,  back,  and  extremities,  but  more  particularly  the 
cervical  rigidity,  explosive  vomiting,  constipation,  photophobia,  sensi- 
tiveness to  sound,  and  hyperesthesia  are  always  suggestive  of  the  disease, 
especially  if  other  cases  have  occurred  in  the  vicinity.  Later,  the  irregu- 
lar temperature,  rapid  or  abnormally  slow  and  weak  pulse,  peculiar  facial 
expression,  emaciation,  muscular  tremor,  soreness  and  rigidity,  the  cry, 
and  other  phenomena  already  reviewed,  establish  the  diagnosis.  Ker- 
nig's  sign  is  a  valuable  aid  to  diagnosis  in  many  cases  in  which  it  is 


114  PRACTICE  OF  MEDICINE 

present,  but  unfortunately  it  is  occasionally  absent.  It  consists  in  a 
peculiar  flexion  of  the  knees  when  the  patient  sits  up  in  bed.  When  the 
patient  lies  upon  his  back  the  legs  can  be  flexed  or  extended  by  the 
hand  of  the  examiner,  but,  if  the  patient  is  raised  into  a  sitting  posture, 
his  knees  become  partially  fl.exed  and  cannot  be  fully  extended  on  ac- 
count of  contraction  of  the  flexor  muscles.  The  extreme  limit  of  flexure 
is  usually  under  135°  it  may  be  as  low  as  90°.  The  sign  indicates 
simply  that  the  meninges  are  involved  and  is  not  peculiar  to  this  form 
of  meningitis.  Unfortunately,  cases  of  pneumonia,  typhoid  fever,  and 
other  affections  occur  in  which  the  symptoms  are  suggestive  of  meningeal 
involvement,  and  other  forms  of  meningitis  must  be  excluded. 

Simple  meningitis  is  often  difficult  to  differentiate  in  the  absence  of 
an  epidemic.  As  a  rule,  the  onset  is  less  severe,  the  tremor,  contrac- 
tures, and  joint-involvement  are  less  prominent  features;  the  sardonic 
grin  and  hydrocephalic  cry  are  not  typical,  if  present. 

Tubercular  mefiingitis  is  generally  more  insidious  in  its  invasion  and 
appears,  as  a  rule,  in  persons  already  suffering  from  tubercular  infection. 
If  this  be  located  in  the  lung,  the  bacillus  may  be  found  in  the  sputum. 
Lumbar  puncture  proves  a  valuable  aid  in  the  differentiation,  since 
Pfaundler  has  shown  that  the  pressure  of  the  fluid  is  often  greater  in 
tubercular  meningitis  than  in  any  other  condition,  while  the  fluid  may 
remain  nearly  or  quite  clear,  a  condition  never  found  in  the  acute  disease. 

Pneumonia  may  be  complicated  by  meningeal  irritation  or  inflamma- 
tion and  is  then  with  some  difiiculty  distinguished  from  a  complication 
of  cerebrospinal  meningitis,  especially  if  the  latter  disease  be  prevalent 
at  the  time.  In  pneumonia  the  symptoms  point  more  distinctively  to 
an  involvement  of  the  cerebral  meninges  alone.  It  may,  however,  re- 
quire the  lumbar  puncture  and  examination  of  the  spinal  fluid  to  de- 
termine the  real  condition. 

Typhoid  Fever. — In  this  disease  symptoms  referable  to  irritation  of 
the  meninges  do  not  usually  appear  until  the  second  week.  The  history 
of  the  invasion  is  different.  The  rose-spots,  greater  enlargement  and 
firmness  of  the  spleen,  the  absence  of  leucocytosis,  and  positive  reaction 
to  the  VVidal  test  are  usually  sufficient  to  determine  the  condition. 

Typhus  fever  can  usually  be  excluded  by  the  character  of  the  epidemic 
prevailing.  Both  diseases  are,  however,  peculiarly  prone  to  occur  in  bar- 
racks and  jails  and  may  be  differentiated  with  difficulty  in  the  start. 
The  extremely  high  temperature,  dusky  hue  of  the  face,  and  less  pro- 
nounced manifestations  on  the  part  of  the  spinal  muscles  are  often  the 
most  valuable  symptoms. 

Prognosis. — The  course  of  the  disease  is  so  variable  that  the  prog- 
nosis is  made  with  difficulty.  The  mortality  in  different  epidemics  has 
ranged  from  20  to  80  per  cent.  In  mild  cases  convalescence  begins  within 
the  first  week;  malignant  cases  generally  terminate  fatally  within  the 
same  period ;  in  the  ordinary  form  it  begins  in  from  two  to  three  weeks. 
Park  tells  us  that  about  40  per  cent  of  the  cases  in  which  the  diplococci 
are  found  in  the  fluid  removed  by  lumbar  puncture  recover,  while  nearly 
all  those  due  to  the  pneumococcus  and  streptococcus  die.  The  com- 
pleteness of  recovery  can  rarely  be  prognosticated. 

Treatment — The  patient  should  be  isolated  in  a  quiet,  moderately 
darkened  room.    All  excitement  should  be  avoided.    Rest  must  be  secured. 


PNEUMONIA 


IIS 


if  by  the  administration  of  opium.  The  headache,  delirium,  restlessness 
and  cervical  pains  may  be  moderated  by  the  application  of  ice-bags  to 
the  head  and  spine,  but  morphin  or  other  opiate  must  be  resorted  to 
in  severe  cases.  The  bromids  in  large  doses  may  be  sufificient  in  the 
case  of  a  child,  and  when  it  is  found  necessary  to  administer  opium  it 
should  be  the  camphorated  tincture  or  deodorized  tincture,  beginning  with 
a  small  dose.  Urethane  in  30-grain  (2.0)  doses  is  recommended  for  the 
relief  of  the  muscular  twitchings  in  an  adult;  warm  baths  and  cannabis 
indica  for  the  rigidity.  The  high  temperature  is  best  combated  by  cool 
sponging  or  the  wet  pack  whenever  the  temperature  reaches  103°  F. 
(39.5°  C).  The  use  of  the  coal-tar  antipyretics  in  this  case  is  generally 
condemned  on  account  of  the  weakness  of  the  heart  and  consequent 
danger  of  greater  depression.  The  heart  may  be  strengthened  by  the  free 
administration  of  stimulants,  which  are  usually  well  borne.  If  the  res- 
piration becomes  irregular,  atropin  may  be  judiciously  administered 
with  the  morphin.  Ergot  and  belladonna  are  thought,  by  some  writers, 
to  exert  a  beneficial  influence  on  the  meningeal  congestion,  but  are  re- 
garded as  of  doubtful  service  by  others.  Blisters  and  other  irritants 
to  the  nape  of  the  neck  should  be  used,  if  at  all,  only  in  the  early  stage 
on  account  of  the  tendency  to  bedsores.  This  tendency  should  be  further 
guarded  against  by  proper  bathing.  Wet  cups  applied  to  the  nape  of  the 
neck  in  the  beginning  of  the  disease  are  sometimes  found  of  benefit. 

The  diet  should  receive  careful  attention.  During  the  acute  stage 
it  should  be  restricted  to  milk,  broths,  and  beef-juice.  Water  should  be 
plentifully  given.  If  swallowing  becomes  difficult,  resort  to  rectal  ali- 
mentation is  necessary.  The  milk  should  then  be  predigested.  The 
bowels  should  be  kept  freely  open  by  the  saline  cathartics,  perhaps  with 
an  occasional  dose  of  calomel. 

After  the  more  acute  manifestations  have  subsided,  the  iodids  may 
be  administered  with  a  view  to  hastening  the  absorption  of  the  exuda- 
tions ;  the  sirup  of  the  iodid  of  iron  is  especially  indicated  on  account 
of  the  anemia  also  present.  During  the  convalescence,  codliver  oil,  malt, 
strychnin,  iron,  and  arsenic  are  indicated.  Massage  and  electricity 
may  hasten  the  restoration  of  tone  to  the  muscles  after  motion  has 
become  established. 

PNEUMONIA. 

LOBAR  PNEUMONIA,  FIBRINOUS  PNEUMONIA,  CROUPOUS  PNEUMONIA,   PNEU- 
MONITIS,  LUNG  FEVER. 

Pneumonia  occurs  in  all  parts  of  the  world,  and  ranks  as  one  of  the  most  fatal  of 
the  acute  infections.  In  the  United  States  the  mortality  attributed  to  it  is  second  only 
to  that  of  tuberculosis,  and  in  many  of  the  cities  it  outranks  the  latter  disease. 

Definition.— An  acute  infection  caused  by  the  micrococcus  lanceolatus 
and  characterized  by  inflammation  of  the  lungs,  with  fever  and  other 
evidences  of  toxemia. 

Etiology.— Bacteriology.— T\\Q  micrococcus  lanceolatus,  the  recognized 
cause  of  the  disease,  is  known  also  as  the  pneumococcus.  It  is  found 
in  about  90  per  cent  of  all  cases  in  the  pulmonary  exudate,  but  has 
been  repeatedly  found  in  the  mouths  of  healthy  persons.  It  is  seen  in 
the  rusty  sputum,  sometimes  in  the  blood,  and  almost  always  in  the 


ii6  PRACTICE  OF  MEDICINE 

smaller  blood-vessels  after  death.  It  can  be  demonstrated  without 
difficulty,  since  it  takes  up  the  usual  stains  and  is  identified  by  its  fairly 
lancet  or  elliptical  shape  and  encapsulation  in  pairs,  particularly  when 
found  in  the  sputum.  The  usual  avenue  of  infection  is  doubtless  the 
respiratory  passages,  probably  the  lung  itself,  although  Menzer  believes 
that  it  may  occur  through  the  tonsil.  The  viability,  virulence,  and 
other  characteristics  of  the  micrococcus  are  so  different  under  different 
circumstances  that  the  existence  of  more  than  one  species  has  been 
suggested.  Eyre  and  Washburn  distinguish  several  types,  notably  a 
parasitic,  the  most  virulent  and  including  the  pneumococcus,  and 
a  saprophytic,  almost  devoid  of  virulence  and  including  the  species  so 
often  found  in  the  respiratory  passages  of  healthy  individuals. 

Other  Organisms. — The  Friedlander  bacillus  pneumoniae  is  also  found 
in  the  lungs,  but  not  so  uniformly  as  the  pneumococcus.  This  is  a  larger 
organism,  a  short  rod  inclosed  in  a  capsule,  and  it  exhibits  very 
..different  vital  phenomena  from  those  of  the  diplococcus.  The  staphylo- 
coccus and  streptococcus  pyogenes  are  also  found  in  some  cases  usually 
associated  with  the  pneumococcus,  but  they  may  be  found  alone,  partic- 
ularly in  the  pneumonia  of  children.  The  bacilli  of  influenza,  diphtheria, 
and  typhoid  fever  have  each  been  encountered  in  pneumonia. 

The  mode  of  transmission  of  the  disease  is  not  understood.  The 
possibility  of  direct  contagion  has  been  too  little  regarded  in  the  past, 
for  recent  investigations  reveal  a  comparatively  frequent  occurrence  of 
successive  cases  in  the  same  locality,  as  in  the  house  referred  to  by 
Schroder,  which  furnished  32  cases  to  the  clinic  of  Kiel  in  15  years,  6 
of  them  in  one  year.  Endemics  including  many  cases  in  rapid  succession 
have  been  repeatedly  observed  in  prisons,  camps,  and  on  ships.  Tyson 
refers  to  410  cases  among  a  ship's  crew  of  815. 

Age. — The  disease  occurs  at  all  ages.  In  childhood  it  is  more  frequent 
before  the  sixth  year.  Holt's  table  of  500  cases  in  children  under  14 
shows  15  per  cent  of  cases  in  the  first  year,  62  per  cent  between  the 
second  and  sixth,  21  per  cent  from  the  seventh  to  the  eleventh,  and 
only  2  per  cent  after  the  twelfth  year.  Netter  observed  a  case  in  which 
the  disease  was  transmitted  from  the  mother  to  the  fetus,  and  two  in- 
stances in  which  the  blood  from  the  uterine  vessels  of  the  patient  con- 
tained pneumococci.  After  puberty,  from  decade  to  decade,  there  is 
probably  not  much  difference  which  cannot  be  better  attributed  to  other 
influences  than  age. 

Sex. — Men  are  oftener  attacked  than  women,  probably  on  account  of 
greater  exposure. 

Race. — The  negro  in  our  country  is  highly  susceptible. 

Physical  Condition. — The  disease  is  so  common  among  robust  working- 
men  that  it  was  once  thought  to  have  an  affinity  for  persons  in  full 
vigor.  In  many,  if  not  in  a  majority,  of  cases,  however,  there  has  been  a 
previous  impairment  of  health.  This  may  have  been  induced  by  fatigue, 
alcoholism,  a  chronic  disease,  or  a  catarrhal  condition  of  the  respiratory 
passages.  A  previous  attack  affords  only  temporary  immunity  and  it 
seems  to  render  the  individual  more  liable  to  the  disease  in  the  future. 

Some  of  the  other  acute  infections  are  more  or  less  frequently  followed 
by  lobar  pneumonia ;  among  them,  typhoid  fever,  erysipelas,  dysentery, 
and  cerebro-spinal  meningitis.     Tuberculosis  does  not  notably  increase 


PNEUMONIA  117 

the  susceptibility  to  it;  asthma,  emphysema,  and  valvular  diseases  of 
the  heart  are  thought  to  lessen  it.  Excessive  indulgence  in  alcohol  is 
one  of  the  most  universally  recognized  predisposing  causes  of  the  disease. 
In  the  large  proportion  of  the  cases  admitted  to  hospitals  the  disease 
follows  a  debauch.     Many  cases  follow  exposure  to  cold  and  wet. 

Climate  is  not  an  important  factor,  since  the  disease  prevails  almost 
everywhere,  in  warm  climates  as  well  as  in  cold.  In  some  countries,  as 
in  Switzerland,  it  is  met  with  especially  in  the  higher  altitudes.  Winter 
and  spring  are  the  seasons  of  greatest  prevalence  in  our  country. 

Trauma  in  which  the  lung  has  been  injured,  with  or  without  fracture 
of  the  ribs,  has  been  followed  by  pneumonia  in  some  instances,  and  it 
is  possible  that  such  injury  favors  the  entrance  of  the  pneumococcus. 

Morbid  A nafotny.— Three  distinct  stages  are  recognized  in  the  inflam- 
matory process  m  the  lungs  :  Engorgement,  red  hepatization,  and  gray 
hepatization. 

Engorgement.— T\ve  first  stage  is  one  of  hyperemia  or  congestion.  The 
vessels  are  distended  with  blood.  The  affected  portion  of  the  lung  is 
dark  red,  heavier  than  normal,  though  it  still  contains  air,  crepitates 
on  pressure,  and  floats  in  water.  When  it  is  incised,  bloody  serum  flows 
from  the  cut  surface.  The  alveolar  spaces  are  diminished  in  size  by  the 
thickening  of  their  walls,  but  they  contain  as  yet  no  exudate.  With  the 
occurrence  of  exudation  the  condition  passes  into  one  of  solidification  or 
red  hepatization. 

Red  Hepatization. — In  this  stage  the  exudation  soon  becomes  com- 
pletely coagulated  within  the  alveoli.  The  walls  show  less  evidence  of 
congestion  than  in  the  first  stage.  The  lung  is  as  firm  as  liver,  contains 
no  air,  and  is  increased  in  volume  to  such  an  extent  that  it  usually 
shows  the  indentations  of  the  ribs.  It  is  also  friable,  so  that  it  can 
easily  be  crushed  between  the  fingers.  The  surface  of  a  section  is  com- 
paratively dry,  has  a  reddish  brown  color,  and  appears  granular,  owing 
to  the  projection  of  minute  fibrinous  casts  from  the  alveoli.  The  ex- 
udation consists  principally  of  fibrin,  in  the  meshes  of  which  are  numer- 
ous red  blood-corpuscles,  polynuclear  leucocytes,  and  epithelial  cells.  The 
diplococci  can  also  be  seen  in  stained  preparations. 

Gray  Hepatization. — The  conditions  found  at  this  stage  are  the  result 
of  degenerative  changes  in  the  exudate  of  the  previous  stage.  The  lung 
is  still  firm  and  even  more  friable, ,  but  has  a  gray  or  yellowish  gray 
or  mottled  color.  The  cut  surface  has  the  same  color  and  is  smooth 
and  moist.  The  fibrin  and  erythrocytes  have  disappeared,  and  the 
exudate  is  composed  chiefly  of  leucocytes,  epithelial  cells,  and  pus-cor- 
puscles. This  stage  merges  into  the  resolution,  or  perhaps  it  would  be 
proper  to  say  that  it  is  a  part  of  the  latter  process,  having  for  its 
object  the  removal  of  the  exudation.  This  is  accomplished  chiefly  by 
absorption  into  the  blood  current;  in  part  also  by  expectoration. 

The  pathological  process  of  pneumonia  probably  begins  b}'  a  de- 
struction and  desquamation  of  the  epithelium  of  the  finer  bronchi  and 
air-cells  by  the  micrococci,  and,  as  in  other  croupous  inflammations, 
a  coagulable  exudate  forms  on  the  injured  surfaces.  (See  p.  30). 
Later  the  white  corpuscles  migrate  from  the  vessels  into  the  exudate, 
and  the  red  corpuscles  and  fibrin  are  dissolved  by  a  chemical  process 
sometimes  regarded  as  a  form  of  peptonization.     After  the  absorption 


ii8  PRACTICE  OF  MEDICINE 

of  the  exudate  the  epithelium  is  regenerated.  The  entire  process  usually 
runs  its  course  within  ten  days.  When  this  reaches  the  periphery  of  the 
lung,  the  pleura  invariably  becomes  involved  in  a  fibrinous  inflammation. 
Sometimes  the  process  of  resolution  passes  into  suppuration  and  abscess- 
formation,  occasionally  terminating  in  gangrene  of  the  lung. 

The  extent  to  which  the  lungs  are  involved  in  the  disease  is  very 
different  in  diff'erent  cases.  It  may  be  confined  to  a  single  lobe,  or  it 
may  be  more  extensive.  The  lower  lobes  are  most  frequently  involved; 
the  upper  lobes  rank  next.  The  corresponding  lobes  of  both  lungs  are 
sometimes  aff"ected  (double  pneumonia).  The  right  middle  lobe  is  seldom 
independently  involved.  Striimpell,  in  244  cases,  saw  the  right  lung 
affected  in  137,  the  left  in  86,  and  both  lungs  in  21.  Involvement  of 
the  lower  lobe  of  one  lung  simultaneously  with  the  upper  lobe  of  the 
other  lung  is  a  condition  rarely  met  with  (crossed  pneumonia).  It  is 
not  unusual  to  find  red  hepatization  in  one  lobe  and  gray  in  another 
in  the  same  patient.  Less  often  they  are  found  side  by  side  in  the  same 
lobe,  and  occasionally  all  three  stages  are  simultaneously  present. 
These  phenomena  result  from  the  successive  involvement  of  diff^erent 
areas. 

Symptoms. — Typical  Case. — The  incubation  is  probably  short,  only 
a  day  or  two,  for  the  initial  chill  frequently  occurs  within  a  few  hours 
after  some  unusual  exposure.  Prodromal  symptoms  are  often  absent; 
there  may  be  a  catarrh  of  the  upper  respiratory  passages  for  a  day  or 
two;  sometimes  headache,  pains  in  the  limbs,  and  anorexia  are  com- 
plained of.  The  onset  is  almost  always  abrupt  with  a  chill  which  often 
lasts  from  fifteen  to  thirty  minutes  or  longer.  The  chill  may,  however, 
be  slight,  it  is  occasionally  absent,  seldom  repeated.  It  may  seize  the 
individual  in  the  midst  of  his  work;  it  often  comes  on  at'  night  during 
sleep.  While  the  patient  still  shivers,  the  temperature  rises,  and  within 
a  few  hours  it  reaches  104°  or  105°  F.  (40° — 40.5°  C).  Its  course  is 
high  throughout  the  disease,  the  diurnal  fluctuation  often  amounting 
to  but  1°  F.  It  almost  always  terminates  by  crisis.  The  pulse  be- 
comes rapid,  generally  no  to  120,  full  and  bounding,  seldom  becoming 
dicrotic  at  any  time.  Shortly  after  the  chill,  sometimes  before  it,  the 
patient  is  seized  with  a  sudden,  often  agonizing  pain  in  the  affected 
side  of  the  chest.  At  the  same  time,  and  partly  as  a  result  of  the  pain, 
the  respiratory  movements  increase  in  frequency,  and  the  movements 
are  shallow,  particularly  on  the"affected  side.  A  dry,  painful,  suppressed 
cough  is  also  present,  but  in  a  day  or  two  this  becomes  moist,  and  the 
characteristic  bloody,  "rusty"  sputum  is  expectorated.  The  dyspnea 
is  sometimes  distressing,  and  the  expirations  are  frequently  accompanied 
by  moans. 

The  patient's  position  and  appearance  are  often  typical  of  the  disease. 
He  lies  at  first  on  his  back ;  but  as  soon  as  solidification  has  occurred 
he  turns  upon  the  affected  side  and  assumes  an  attitude  of.  restraint, 
avoiding  motion  on  account  of  the  pain  it  occasions.  The  face  is  flushed, 
often  dusky,  and  in  the  center  of  each  cheek,  or  frequently  only  in  that  of 
the  side  corresponding  to  the  affected  lung,  there  is  a  bright  red  spot. 
The  expression  is  that  of  anxiety  and  pain.  The  tongue  is  furred  and 
often  becomes  dry  and  brown.  Vomiting  sometimes  occurs,  especially 
in  children;  the  bowels  are  generally  constipated.     A  herpetic  eruption 


PNEUMONIA 


119 


appears  in  about  a  third  of  the  cases,  on  the  Kps,  about  the  angles  of 
the  mouth,  on  the  chin  or  nose,  occasionally  about  the  eyes,  or  on  the 
helix  of  the  ear,  rarely  on  the  genital  or  anal  region.  Sleep  is  usually 
restless,  or  insomnia  may  prevail.  Delirium  not  infrequently  develops; 
it  is  especially  frequent  and  severe  in  alcoholic  subjects. 

The  disease  runs  its  course  in  from  three  to  ten  days ;  then,  as  a  rule, 
terminates  by  crisis.  The  temperature  falls  within  a  few  hours  to  the 
normal  or  lower,  the  pulse 
and  respiration  become 
slow,  pain  and  dyspnea 
vanish,  and  the  patient  falls 
into  his  first  peaceful  slum- 
ber. For  a  few  hours  he  is 
usually  bathed  in  a  profuse 
sweat ;  diarrhea  sometimes 
occurs,  but  soon  ceases  after 
the  crisis  is  over.  The  cough 
may  continue  for  a  few  days, 
but  the  blood  disappears 
from  the  sputum  and  the 
quantity  of  the  expectora- 
tion rapidly  diminishes. 
Convalescence  is  usually 
rapid,  and  recovery  may  be 
complete  within  a  week  or 
ten  days. 

Special  Synrzfoms.  —  T//e 
CJiilL — There  is  no  other 
disease  in  which  the  inva- 
sion is  so  constantly  an- 
nounced by  chill  or  in  which 
the  chill  is  uniformly  so 
severe.  It  is  a  pronounced 
rigor,  often  lasting  more 
than  a  half-hour;  it  is  sel- 
dom repeated.  Chills  may, 
however,  occur  during  the 
course  of  the  disease,  and 
then  generally  signify  an 
involvement  of  an  additional 
area  of  the  lung.  The  chill 
is  absent,  according  to  some 
observers,  in  about  20  to 
30  per  cent  of  the  cases. 

The  Fever. — The  distinc- 
tive features  of  the  fever  are 
the  sudden  rise  of  temperature, often  to  104°  or  105°  F.  (40°— 4o.5°C.) 
within  12  hours;  its  uniform  course  frequently  not  varying  more  than  1° 
or  1.5°  F.  during  two  or  three  days,  audits  termination  by  crisis.  The 
surface  temperature  often  shows  comparatively  little  increase ;  hence  the 
rectal  temperature  may  be  several  degrees  higher  than  that  of  the  axilla. 


F. 

106' 

105° 
104 
103 

102 

0 
101 

100° 

0 
99 

0 
98 

DAY  OF 
DISEASE 

M    I    E   j   M       E   :   M 

E    1   M       E 

M 

E 

M 

E 

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Fig.  1 1  .—Temperature  chart  of  pneumonia,  termi- 
nating by  crisis  on  the  sixth  day.    (Ziegter.) 


120  PRACTICE  OF  MEDICINE 

Irregular  types  of  fever  are  sometimes  observed,  as  when  the  tempera- 
ture, alone  or  along  with  the  other  symptoms,  more  or  less  completely 
subsides  before  the  crisis.  A  drop  to  normal,  with  amelioration  of  the 
other  symptoms,  sometimes  occurs,  and  is  then  followed  by  a  hyperpyrexia 
which  in  turn  ushers  in  the  crisis.  A  convulsion  or  vomiting  sometimes 
takes  the  place  of  the  chill  in  children,  in  whom  the  rise  of  temperature 
is  also  more  gradual  and  the  daily  fluctuation  may  be  greater.  The 
same  conditions  are  sometimes  observed  in  adult  cases  beginning  without 
a  chill.  In  very  old  persons  the  temperature  may  be  but  slightly  elevated, 
and  the  termination  is  often  by  lysis.  Hyperpyrexia  is  not  uncommon. 
The  temperature  may  reach  107°  or  108°  F.  (41.6°— 42.2°  C),  even 
109.5°  F.  (43.0°  C),  as  in  a  case  reported  by  Ironside. 

The  crisis  may  occur  at  any  time  from  the  third  to  the  tenth  or 
twelfth  day.  A  peculiar  frequency  of  its  occurrence  on  odd  days,  as  on 
the  seventh,  ninth,  or  eleventh,  has  been  repeatedly  noted,  but  it  not 
infrequently  occurs  as  early  as  the  end  of  the  sixth  day.  The  fall  of 
temperature  is  often  very  abrupt,  and  it  may  amount  to  5°  or  6°  F. 
(^2.7°— 3.3°  C.)  within  from  three  to  eight  hours,  sometimes  becoming 
from  I  °  to  3  °  F.  subnormal.  The  temperature  sometimes  rises  one  or 
two  degrees  just  before  the  crisis,  and  it  may  rise  to  102°  or  103°  F. 
(x<^.Q° — 39.5°  C.)  in  24  hours  after  the  crisis  and  remain  elevated  for 
two  or  three  days. 

A  pseudoc/'isis  is  sometimes  observed  in  which,  particularly  on  the 
fifth  or  sixth  day  of  the  disease,  the  temperature  falls  to  101°  or  102° 
F.  (38-5°— 39-o°  C),  but  immediately  rises  again  to  its  former  height. 
It  is  usually  indicative  of  the  involvement  of  additional  lung  space. 
The  crisis  may  still  occur,  but  lysis  is  the  usual  termination  in  protracted 
cases. 

Fain  is  constantly  present  at  the  beginning.  It  may  subside  to  a 
great  extent  after  complete  solidification  of  the  lung.  It  is  often  ex- 
cruciating, and  is  greatly  increased  by  coughing  or  efforts  at  full  in- 
spiration. In  a  double  pneumonia  the  moans  of  the  patient  can  often  be 
heard  at  a  great  distance,  notwithstanding  the  restricted  breathing. 
The  pain  is  confined  to  the  affected  side  of  the  chest  and  is  usually 
referred  to  the  lower  axillary  space  or  to  the  region  of  the  nipple.  The 
pain  is  probably  due  almost  solely  to  the  accompanying  pleurisy,  for  it 
is  often  shght  in  a  central  pneumonia. 

The  dyspnea  varies  in  severity  with  the  extent  of  lung  involved,  the 
degree  of  temperature,  the  amount  of  pain,  and  probably  in  a  great 
measure  with  the  extent  to  which  the  toxemia  affects  the  respiratory 
centers.  It  is  always  a  prominent  symptom.  The  respiratory  movements 
are  usually  increased  to  30  or  40,  often  to  50  or  60  a  minute.  In 
children  they  may  reach  80  or  100.  They  are  shallow,  but  regular, 
as  a  rule.  The  dyspnea  is  accompanied  by  the  usual  signs,  movement 
of  the  alse  nasi,  and  a  sense  of  suffocation  or  of  constriction  beneath 
the  sternum.  But,  as  Grisolle  remarks,  the  most  rapid  respiratory 
movements  in  some  patients  may  be  only  a  manifestation  of  nervous 
irritation  at  the  pain  and  may  not  denote  so  great  dyspnea  as  is  often 
indicated  by  24  or  28  respirations  a  minute  in  other  cases.  The  disturb- 
ance of  the  ratio  of  respiration  to  pulse-rate  is  a  striking  and  charac- 
teristic feature  of  pneumonia.    Instead  of  the  normal  ratio  of  i  14,  it  is 


PNEUMONIA         ^  121 

often  1:2  or  i  :i.5,  for  the  pulse  may  be  only  120  when  the  respira- 
tions are  60  or  more. 

Pulse  and  Heart. — The  acceleration  of  the  pulse  is  moderate  in  most 
cases,  being  strikingly  out  of  proportion  to  the  respiration  as  stated 
in  the  last  paragraph.  The  pulse  is  usually  full  and  bounding  in  the 
beginning;  it  may  become  weak  after  a  iesff  days  and  occasionally  di- 
crotic. In  alcoholic  cases  and  old  persons,  it  is  frequently  feeble  and 
rapid  from  the  beginning.  The  second  sound  of  the  heart  is  accentuated 
owing  to  the  increased  tension  in  the  pulmonary  circulation,  and  a 
temporary  systolic  murmur  is  often  heard  over  the  pulmonary  valve; 
sometimes  also  over  the  mitral.  A  fatal  cardiac  distention  or  paralysis 
sometimes  results  from  trifling  exertion  in  the  presence  of  profound 
toxemia. 

The  cough  is  an  early  symptom,  rarely  absent  except  in  infants  and 
very  aged  or  feeble  persons,  but  it  may  be  suppressed  on  account  of 
the  agonizing  pain  which  is  occasioned  by  it.  It  is  at  first  short,  sharp, 
and  dry,  but  by  the  second  or  third  day  it  is  attended  with  expectora- 
tion. The  sputum  is  at  first  mucous  in  character,  but  after  24  to  48 
hours  it  becomes  tinged  with  bright  arterial  blood.  The  color  soon 
changes  to  an  orange-yellow,  iron-rust  color,  which  has  given  it  the 
name  of  rusty  sputum.  Free  hemoptysis  occasionall}^  occurs  at  the 
onset  of  the  disease.  The  sputum  is  often  so  tenacious  and  viscid  that 
it  clings  to  the  tongue  and  lips  and  is  wiped  away  with  difficulty;  the 
cup  can  often  be  inverted  without  spilling  it.  In  some  cases,  however, 
particularly  in  asthenic  cases,  the  sputum  is  more  fluid  and  has  the 
dark  brown  color  of  prune-juice,  a  name  often  applied  to  it.  The  quan- 
tity of  the  expectoration  is  exceedingly  variable.  Occasionally  there  is 
no  expectoration,  or  the  sputum  may  pass  into  the  esophagus  and 
escape  observation,  particularly  in  women  and  children  or  in  the  presence 
of  extreme  prostration.  Microscopic  examination  of  the  sputum  reveals 
numerous  degenerated  bronchial,,  probably  also  alveolar,  epithelial  cells, 
normal  and  degenerated  erythrocytes  and  leucocytes.  The  micrococcus 
lanceolatus  and  other  bacteria  are  often  present  in  great  numbers. 

Cerebral  Disturbances. — Headache  is  a  common  symptom.  Convulsions 
rarely  occur  except  at  the  beginning  of  the  disease  in  children.  In  some 
cases  of  so-called  cerebral  pneumonia  in  children,  the  rigidity  and  re- 
traction of  the  neck,  and  the  muscular  twitching  form  a  picture  very 
suggestive  of  cerebrospinal  meningitis.  Delirium  is  a  not  unusual  symp- 
tom, especially  in  alcohohc  subjects,  children,  and  the  aged.  It  is  often 
mild  in  character,  but  it  may  become  maniacal,  particularly  in  the 
drunkard.  Typical  delirium  tremens  not  infrequently  develops  on  the 
third  or  fourth  day  in  these  cases.  Such  patients  often  show  a  propen- 
sity for  getting  out  of  bed,  and  have  jumped  out  of  windows  in  the 
absence  of  the  attendant.  Delirium  is  frequently  absent,  however,  even 
in  fatal  cases  among  alcoholic  patients.  Exceptionally,  the  delirium, 
instead  of  ceasing  at  the  crisis,  becomes  more  violent  for  a  itw^  hours, 
and  in  another  class  of  cases  it  makes  its  first  appearance  at  this  time, 
but  it  is  then  usually  of  short  duration.  Other  cerebral  disturbances 
continuing  after  the  crisis  usually  terminate  favorably. 

Toxefnia.— Casts  are  now  and  then  observed  in  which  toxemia  resem- 
bling uremia  is  present.    Chill,  pain,  and  cough  may  all  be  absent  in  the 


122  PRACTICE  OF  MEDICINE 

beginning,  and  the  fever  slight,  but  in  a  few  days  the  temperature  rises 
and  the  patient  passes  into  a  low,  muttering  dehrium,  or  a  coma  which 
proves  rapidly  fatal. 

The  Blood.— The  most  characteristic  feature  of  the  blood  is  simple 
leucocytosis,  developing  early,  continuing  to  the  crisis  and  sometimes 
reaching  the  extent  of  from  30,000  to  60,000  per  c.mm.,  or  from  three 
to  eleven  times  the  normal  limit.  Polynuclear  corpuscles  are  most  abun- 
dant in  the  beginning,  but  eosinophiles  become  numerous  later.  Absence 
of  leucocytosis  is  an  unfavorable  sign  usually  seen  in  protracted  cases. 
Stockton,  however,  reports  the  case  of  a  httle  girl  with  two  relapses  and 
ultimate  recovery,  in  which  there  were  only  4,000  leucocytes  to  the  c.mm. 
during  the  first  relapse.  As  is  remarked  by  Thompson,  the  theory  that 
the  leucocytes  are  active  agents  in  the  production  of  immunity  receives 
much  support  from  this  clinical  fact.  It  may  be  applied  thus  :  "  The 
toxin  formed  by  the  pneumococci  is  active  for  a  few  days  until  sufficient 
leucocytes  accumulate  to  manufacture  antitoxin  to  destroy  it,  producing 
a  crisis.  Absence  of  leucocytosis  gives  free  scope  to  the  toxin  in  severe 
cases.  Insufficient  leucocytosis  '  postpones  the  crisis  and  resolution." 
The  micrococci  are  recognized  in  the  blood  with  difficulty. 

The  urine  is  high  in  color,  specific  gravity,  and  solids,  particularly 
in  uric  acid,  and  a  trace  of  albumin  is  often  present.  As  in  other  fevers 
the  chlorids  are  generally,  though  not  always,  diminished,  a  phenomenon 
which  is  perhaps  best  explained  by  Koranyi's  theory  of  molecular  inter- 
change in  the  kidney.  F.  Pick  calls  attention  to  the  fact  that  in  from 
24  to  48  hours  after  the  crisis  the  urine  often  becomes  neutral  or  alka- 
line for  a  period  of  24  to  36  hours,  after  which  the  acidity  returns. 
Sternberg  regards  secondary  infection  of  the  uriniferous  tubules  by  the 
pneumococcus  as  probably  not  infrequent.  The  toxicity  of  the  urine 
has  been  found  greatly  reduced  during  the  disease. 

Physical  Examination.— i.  During  the  stage  of  congestion,  inspection 
shows  a  diminution  of  the  movement  of  the  affected  side,  and  in  double 
pneumonia  the  breathing  is  chiefly  abdominal.  By  palpation,  an  in- 
creased fremitus  is  generally  noticed  over  the  affected  area.  Percussion 
reveals  dullness  or  a  high-pitched  tympanitic  note  over  the  region  in- 
volved and  a  tympanitic  note  over  the  surrounding  region  of  the  lung. 
On  auscultation,  the  breathing  is  found  to  be  bronchovesicular  in  char- 
acter and  it  is  reduced  in  amplitude.  An  exaggerated  respiratory  mur- 
mur may  be  heard  over  the  other  regions  of  the  chest.  Subcrepitant 
rales  are  usually  present,  or  the  crepitant  rale  may  be  heard  at  the 
end  of  a  forced  inspiration. 

2.  S^a^e  of  Hepatizatio7i.—Inspectio7i.—T\v^  respiratory  movement  of 
the  affected  side  is  much  limited  if  an  entire  lobe  is  involved,  and  a 
corresponding  increase  in  that  of  the  opposite  side  is  observed.  The 
healthy  side  of  the  chest  may  appear  larger  than  the  affected  side.  The 
tactile  fremitus  is  generally  increased.  A  pleuritic  friction  fremitus  may 
be  felt.  On  percussion  the  note  varies  from  a  tympanitic  dullness  to 
flatness;  occasionally  a  metallic  quality  can  be  detected.  In  central 
pneumonia  the  dullness  may  be  almost  unrecognizable,  although  the 
sense  of  resistance  imparted  to  the  finger  may  be  increased.  In  children, 
careful,  light  percussion  is  always  required  to  elicit  dullness.  Ausculta- 
tion reveals  typical  tubular  breathing  and  bronchophony  in  most  cases; 


PNEUMONIA  123 

rarely  egophony,  over  the  afifected  area.  Subcrepitant  rales  are  not 
infrequently  heard.  All  sounds  may  cease  when  the  bronchi  become 
completely  closed  by  the  exudate. 

3.  Resolution. — During  this  period  the  respiratory  movements  become 
less  restricted  and  percussion  resonance  gradually  increases.  The  sub- 
'  crepitant  soon  give  place  to  coarser  moist  rales,  which  may  continue 
throughout  the  week  or  more  of  absorption  of  the  exudate.  The  res- 
piration again  becomes  bronchovesicular  and  finally  returns  to  its 
normal  quality. 

Varieties  of  Pneumonia. — This  term  is  employed,  not  to  designate 
different  types  of  the  disease,  but  rather  the  different  features  presented 
in  different  cases.  The  affection  is,  so  far  as  is  known,  the  same  in  all 
cases,  and  the  variations  probably  result  from  differences  in  the  age, 
vulnerability  or  susceptibility  of  the  patient,  or  from  accidental  or 
unrecognizable  influences.  The  terms  apical  and  basal  are  sometimes  ap- 
plied to  the  disease  to  indicate  that  the  apex  or  the  base  is  involved. 

Frank  pneumotiia  is  merely  a  synonym  for  the  ordinary  type  of  the 
disease. 

Epidemic  pneumonia  is  usually  a  virulent  type,  often  occurring  in 
individuals  previously  debilitated  by  influenza  or  other  infection. 

Migratory  pneimioiiia  is  a  frequently  fatal  form  in  which  one  area 
after  another  is  iuA/olved  until  the  vitality  of  the  patient  has  been 
exhausted. 

Massive  pneumonia  is  that  condition  in  which  an  unusually  large 
area  of  the  lung  is  solidified  and  the  bronchi  are  completely  filled  with 
the  exudate.    Expectoration  may  be  absent. 

Central  pneicmonia  is  a  rather  frequent  form,  at  least  in  the  beginning 
of  the  attack.  In  it  the  exudation  is  often  confined  to  the  center  of  a 
lobe  or  to  the  base  of  the  lung  and  does  not  reach  the  periphery  during 
the  first  two  or  three  days  of  the  disease.  Both  the  subjective  and 
objective  signs  may  be  very  indefinite  during  this  time. 

Secondary  pneumonia  is  a  term  sometimes  used  when  the  disease  has 
developed  as  a  complication  of  other  infectious  diseases.  The  base  of 
the  lung  is  usually  affected  and  the  diagnosis  may  be  difficult,  particu- 
larly when  other  micro-organisms  than  the  pneumococcus  are  present. 

Bacelli  describes  a  form  of  pneumonia  which  follows  pleurisy.  The 
signs  of  pleurisy  are  distinct  on  the  first  day.  On  the  fourth  or  fifth, 
symptoms  of  intense  pulmonary  edema  appear,  dyspnea,  serous  sputum, 
blood-stained  or  hemorrhagic.  The  disease  runs  a  rapid,  often  fatal 
course. 

Terminal  pneumonia  signifies  that  the  disease  has  developed  in  an 
aged  person  or  one  who  is  the  subject  of  a  chronic  disease.  In  other 
words,  it  becomes  the  fatal  termination  of  senile  debility,  tuberculosis, 
cancer,  cardiac  or  renal  disease.  This  part  is  more  frequently  played, 
however,  by  bronchopneumonia  or  hypostatic  congestion. 

Alcoholic  pneumonia  is  often  masked  by  the  predominance  of  the  acute 
symptoms  of  intoxication.  It  should  be  recognized,  however,  upon  ex- 
amination, the  necessity  of  which  is  indicated  by  high  temperature, 
rapid  respiration,  dyspnea,  often  with  cyanosis. 

Typhoid  pneumonia  is  a  term  without  much  to  recommend  it.  It  is 
used  to  designate  either  pneumonia  complicating  typhoid  fever,   or  a 


124 


PRACTICE  OF  MEDICINE 


condition  of  stupor  like  that  of  typhoid  fever  supervening  upon  a  lobar 
pneumonia.    Either  condition  is  grave. 

Pneumonia  in  infants  usually  begins  wdth  a  convulsion  and  runs  an 
irregular  course,  often  affecting  the  apex,  attended  with  delirium,  and 
terminating  by  lysis,  occasionally  by  crisis.     (Fig.   12). 

Pneui7i07iia  in  the  Aged. — The  peculiarities  of  the  disease  in  old  people 
have  already  been  stated.  Bronchopneumonia  is  more  common  in  them, 
as  also  in  children. 


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Fig.  12. — Temperature  chart  of  a  case  of  pneumonia,  terminating  b}-  crisis,  in  an  infant 
of  nine  months.     Pseudocrises  are  shown   also  upon  the  sixth  and  ninth  days. 

Apyretic  pneumonia  has  been  described.  Guider  attributes  the  ab- 
sence of  fever  to  exhaustion  of  the  economy,  functional  disturbance 
of  the  nervous  system,  and  the  action  of  infectious  agents. 

Pneu7no7iia  after  Surgical  Operations. — The  occurrence  of  lobar 
pneumonia  after  surgical  operations  is  probably  purely  accidental  and 
is  very  infrequent.  Ether  pneumonia  and  respiration  pneumonia  are 
both  bronchopneumonias  and  should  not  be  confounded  with  this 
disease. 

Delayed  Resolution. — In  a  typical  case  of  pneumonia,  resolution 
does  not  occupy  more  than  a  week  or  ten  days.  The  cough  ceases, 
and  physical  examination  reveals  no  abnormal  condition  further  than 
slight  dullness  due  to  thickening  of  the  pleura.  This  dullness  some- 
times persists  for  a  month  or  more.  The  resolution  is  sometimes  de- 
layed beyond  the  usual  limit,  particularly  in  debilitated  subjects,  but 
sometimes  also  in  robust  individuals  in  whom  the  slow  recovery  is  unac- 
countable. In  some  cases  the  consolidation  of  lung  continues,  with  or 
without  fever.  In  other  cases,  after  the  temperature  has  subsided  by 
crisis  or  lysis,  it  returns  again  at  intervals,  or  runs  an  irregular  course 
for  several  weeks.  There  may  be  intense  b-onchial  breathing,  but  there 
is  usually  no  cough  or  expectoration.  In  other  cases,  again,  the  moist 
rales  and  expectoration  continue.  The  temperature  curve  and  frequent 
sweating  in  some  cases  suggest  the  possibility  of  sepsis.    Tuberculosis 


PNEUMONIA  125 

rarely  follows  lobar  pneumonia,  but  a  latent  pulmonary  tuberculosis 
may  be  awakened  by  it. 

Relapse. — A  true  relapse  of  pneumonia  is  seldom  seen.  In  some  cases, 
however,  there  is  an  apparent  recrudescence  due  to  delayed  resolution 
or  to  the  development  of  complications.  In  other  cases  the  apparent 
relapse  is  due  to  the  invasion  of  additional  lung  space,  with  return  of 
the  S3-mptoms,  at  a  time  when  the  crisis  is  being  looked  for,  but  the 
condition  can  hardly  be  regarded  as  a  relapse. 

Recurrence  is  not  infrequent.  There  have  been  well-authenticated  in- 
stances in  which  the  same  person  passed  through  eight  or  ten  attacks. 

Complications  and  Sequelae. — Pleurisy  is  so  constantly  an  accom- 
paniment of  pneumonia  that  it  may  well  be  looked  upon  as  a  part  of 
the  disease,  rather  than  as  a  complication.  It  is  absent  only  in  central 
pneumonia  before  the  inflammation  has  reached  the  surface.  In  some 
cases,  again,  the  pleural  inflammation  predominates  to  such  a  degree 
that  the  condition  is  frequently  spoken  of  as  a  pleuro-pneumonia.  The 
fibrinous  exudation  is  always  unusually  abundant  in  these  cases  and 
interposes  a  thick  cushion  between  the  consolidated  lung  and  the  chest 
wall,  greatly  interfering  with  the  transmission  of  the  respiratory  sounds. 
A  serofibrinous  form  of  pleurisy  is  not  infrequently  encountered  in  long- 
continued  cases.  Occasionally  it  becomes  suppurative  and  an  empyema 
may  be  developed.  In  such  cases  it  is  the  rule  to  find  both  the  pneu- 
mococcus  and  streptococcus  in  the  fluid.  The  condition  is  recognized 
by  a  continuance  of  the  fever,  usually  with  a  remittent  or  intermittent 
course,  and  persistence  of  the  leucocytosis,  frequently  with  sweating  and 
other  signs  of  pyothorax.  The  diagnosis  is  established  by  the  with- 
drawal of  pus  through  the  aspirator  needle. 

Endocarditis  is  a  comparatively  frequent  complication,  especially  in 
the  presence  of  an  old  valvular  lesion,  and  perhaps  for  that  reason  it 
is  more  frequent  in  the  left  heart.  It  may  follow  the  crisis.  Its  develop- 
ment is  often  concealed,  there  being  no  murmur  even  in  severe  cases; 
and,  as  already  stated,  a  murmur  may  be  present  for  a  time  without 
lesion  of  the  valves.  In  other  cases,  a  rough  diastolic  murmur  is  heard. 
A  malignant  endocarditis  is  to  be  suspected,  however,  when  chills,  ir- 
regular fever,  and  sweating  continue  to  occur,  and  particularly  when 
embolic  infarctions  develop  in  any  of  the  organs.  The  pneumococcus  is 
sometimes  found  in  the  cardiac  vegetations  after  death.  Meningitis  is  not 
infrequently  associated  with  a  malignant  endocarditis  of  this  character. 

Pericarditis  is  seldom  met  with  in  adults  and  is  more  frequent  in  the 
left-sided  pneumonia  of  young  children.  It  is  a  result  of  an  extension 
of  the  inflammation  from  the  left  pleura  to  the  pericardium.  It  may  be 
recognized  early,  before  eff'usion  has  taken  place,  by  the  friction  sound, 
or  if  this  be  absent,  by  the  precordial  pain,  increased  heart  dullness, 
intense  dyspnea,  indistinct  heart  sounds,  and  the  feeble  pulse. 

Embolism  has  been  found  in  the  larger  arteries ;  thrombi  occasionally 
form  in  the  veins.  Aphasia,  with  or  without  hemiplegia,  has  been  ob- 
served in  a  few  instances,  probably  as  a  result  of  embolism. 

Meningitis,  attributed  to  the  migration  of  the  pneumococcus,  is  en- 
countered during  the  height  of  the  fever  in  some  cases.  It  usually  affects 
the  cerebral  cortex,  but  is  much  more  easily  recognized  when  it  attacks 
the  base.     It  is  then  indicated  by  severe  headache,  sluggish  response  or 


126  PRACTICE  OF  MEDICINE 

unequal  dilatation  of  the  pupils,  rigidity  and  retraction  of  the  neck,  with 
a  tendency  to  delirium  or  stupor. 

Croupous  colitis  occasionally  develops  late  in  the  disease. 

Jaundice  appears  early  in  some  cases.  It  is  seldom  severe  in  char- 
acter. The  mode  of  its  production  is  not  understood.  Some  writers 
regard  it  as  a  true  hematogenous  icterus. 

Acute  articular  rheumatism  may  precede,  accompany,  or  follow  pneu- 
monia, and  it  is  frequently  accompanied  by  endocarditis  or  pleurisy. 
Among  the  rarest  complications  are  acute  nephritis,  otitis  media, 
croupous  gastritis,  parotitis,  peritonitis,  and  peripheral  nueritis.  Ab- 
scess and  gangrene  of  the  lung  sometimes  follow  imperfect  resolution. 

Diagnosis. — Pneumonia  is  seldom  difficult  of  recognition  except  in 
children  and  very  old  or  feeble  patients,  too  weak  to  expand  the  chest 
and  bring  out  the  auscultatory  signs.  It  may  be  readily  overlooked 
when  it  develops  insidiously  during  the  course  of  another  affection. 
The  attitude  in  bed,  the  anxious  expression,  flushed  face  with  bright  red 
cheek,  the  chill,  fever,  pain,  rapid  pulse  with  disproportionately  rapid 
breathing,  the  cough  and  expectoration  of  rusty  sputum,  leave  little 
chance  for  error  in  a  typical  case.  When  there  are  added  to  this  the 
physical  signs,  particularly  the  bronchial  breathing  and  the  crepitant 
rale,  the  picture  is  complete.  In  children  the  diagnosis  is  often  difficult 
either  on  account  of  the  predominance  of  meningeal  irritation  or  the 
absence  of  characteristic  features.  Percussion  must  always  be  performed 
with  delicacy  in  a  child  in  order  to  elicit  the  dullness,  for  a  resonant  tone 
may  be  transmitted  from  the  viscera  beyond  the  area  of  consolidation, 
on  forcible  percussion.  An  agglutinative  reaction  has  been  obtained 
upon  the  pneumococcus  with  the  serum  of  individuals  suffering  from 
pneumococcus  infection,  but  its  utility  as  a  test  for  the  disease  has  not 
yet  been  demonstrated. 

Pleurisy  and  Empyema. — A  pleuritic  effusion,  especially  if  purulent^ 
may  cause  confusion  unless  the  exploratory  needle  is  used.  In  pneu- 
monia, however,  there  is  no  displacement  of  the  heart  or  other  viscera, 
as  in  hydrothorax.  The  presence  of  vocal  and  tactile  fremitus  cannot 
be  relied  upon  in  the  exclusion  of  pyothorax. 

Acute  pneumonic  phthisis  runs  a  slower  course,  as  a  rule.  The  sputum 
has  the  prune-juice  appearance  rather  than  the  rusty  color,  and  the 
sweating,  rapid  emaciation,  and  irregular  temperature  are  distinctive. 
The  delirium  is  often  more  constant  and  more  severe  than  that  of  pneu- 
monia. 

Typhoid  fever  may  begin  with  rapid  respiration  and  other  symptoms 
suggesting  pneumonia,  and,  on  the  other  hand,  the  pneumonia  patient 
may  sink  into  a  typhoid  stupor.  The  temperature  curves  are  quite 
different,  and  the  absence  of  the  rusty  sputum,  the  presence  of  rose- 
spots,  pea-soup  stools,  a  positive  Widal  reaction,  and  the  absence  of 
leucocytosis  in  the  former  disease  render  the  distinction  positive  in 
most  cases. 

Prognosis. — Pneumonia  is  one  of  the  most  fatal  of  the  acute  infec- 
tious diseases.  The  prognosis  is  modified,  however,  by  the  age,  sex, 
and  vigor  of  the  patient,  and  to  a  very  marked  extent  by  his  habit  as 
to  indulgence  in  alcohol.  In  private  practice  the  mortality  is  usually 
from  lo  to  15  per  cent,  in  hospitals  from  20  to  30  per  cent.     In  epi- 


PNEUMONIA 


127 


demies  it  often  exceeds  50  per  cent.  The  death-rate  is  very  different 
in  different  localities,  at  different  seasons,  and  in  different  classes  •  of 
patients.  It  is  more  fatal  in  the  extremes  of  life.  Infants  under  one 
year  and  adults  over  65  seldom  recover.  Alcoholic  subjects  and  the 
victims  of  chronic  disease  are  especially  liable  to  succumb.  Children 
almost  invariably  recover,  and  the  prognosis  is  generally  favorable  in 
robust  adults  of  middle  age.  Much  depends  in  any  case  upon  the  degree 
of  the  toxemia,  as  manifested  by  high  fever,  delirium,  prostration,  and 
feeble  circulation.  Diffuse  bronchitis  adds  gravity  to  the  case.  Absence 
or  deficiency  of  leucocytosis  indicates  feeble  resistance  on  the  part  of 
the  economy;  and  increased  heart  action,  cyanosis,  or  disappearance 
of  the  second  sound  over  the  pulmonary  valve  late  in  the  disease  are 
of  evil  import,  indicating  a  failure  on  the  part  of  the  heart.  Death  is 
usually  due  to  an  intense  action  of  the  toxin  upon  the  heart  or  central 
nervous  system,  or  a  sudden,  fatal  dilatation  of  the  right  heart,  seldom 
solely  from  interference  with  the  respiration,  even  in  extreme  cases  of 
double  pneumonia.  A  complicating  endocarditis  is  not  necessarily  fatal, 
but  a  meningitis  is  almost  always  so.  The  pulse  is  not  always  a  safe 
guide  to  the  prognosis,  for  a  slow,  full,  compressible  pulse  often  ac- 
companies the  failure  of  the  circulation  which  precedes  death  by  only  a 
few  hours. 

Prophylaxis. — Comparatively  little  is  known  on  this  subject.  Prob- 
ably too  little  attention  has  been  given  to  the  danger  of  communi- 
cating the  disease  through  careless  disposal  of  the  sputum.  The  fact 
that  in  a  few  instances  the  nurse  has  become  infected  while  waiting 
upon  the  pneumonic  patient  suggests  the  advisability  of  adopting 
measures  of  thorough  antisepsis,  including  destruction  of  the  sputum  by 
fire  or  steam  and  thorough  disinfection  of  the  apartments  after  the  re- 
covery of  the  patient.  N.  S.  Davis,  Jr.,  recommends  the  use  of  anti- 
septic mouth-washes  several  times  a  day. 

Treatment — General. — The  treatment  of  a  case  is  chiefly  symptomatic. 
We  have  no  means  of  cutting  short  an  attack,  and  probably  none  of 
greatly  modifying  its  course.  As  Osier  remarks,  '"  Patients  are  more 
frequently  damaged  than  helped  by  the  promiscuous  drugging  which  is 
still  too  prevalent."  Good  nursing  and  the  amelioration  of  symptoms 
are,  however,  requisite.  The  patient  should  be  placed  in  a  quiet,  sunlit, 
well-ventilated  room  kept  at  a  temperature  between  65°  and  70°  F. 
(18° — 20°  C).  Visitors  should  be  excluded.  Ordinary  ventilation  is 
not  enough.  The  patient  should  be  placed  in  the  open  air  or  directly 
at  an  open  window  when  the  weather  will  permit.  The  relief  experienced 
in  a  severe  case  by  this  treatment  is  remarkable.  Frequent  sponging 
is  beneficial  for  stimulation  and  for  the  reduction  of  temperature.  The 
Brand  method,  however,  has  not  given  good  results.  The  cold  pack 
may  be  employed,  and  the  warm  plunge  of  90°  F.  (32.0°  C.)  is  beneficial 
to  children.  The  diet  should  be  liquid;  milk,  broths,  gruels,  and  soft 
eggs  may  be  given.  Plenty  of  water,  plain  or  carbonated,  or  lemonade 
should  be  given  at  regular  intervals.  The  patient  should  under  no  cir- 
cumstances be  permitted  to  raise  even  his  head.  Food  should  be  adminis- 
tered through  a  tube.  The  bowels  should  be  kept  open.  A  dose  of  calomel 
may  be  given  in  the  beginning,  and  a  saline  laxative  at  intervals  during 
the  disease.    Tympanites  must  be  immediately  relieved  by  the  application 


128  PRACTICE  OF  MEDICINE 

of  turpentine  stupes  or  the  adminstration  of  5  to  10  drops  of  turpentine 
every  hour  or  two,  on  account  of  its  interference  with  respiration.  The 
rectal  tube  will  sometimes  remove  the  flatus. 

Local  applications  of  heat  or  cold,  especially  the  application  of  the  con- 
tinuous ice-bag,  to  the  affected  side  afford  great  relief.  Counter-irritants 
are  still  employed  by  some,  blisters  are  rarely  used.  The  pneumonia 
jacket,  consisting  of  a  thick  layer  of  cotton  covered  with  oil  silk,  is  em- 
ployed by  some  physicians,  but  it  is  generally  better  to  leave  the  chest 
accessible.  Bleeding  at  the  beginning  of  the  disease  has  been  found 
highly  beneficial  in  robust  individuals  with  full,  bounding  pulse,  prom- 
inent arteries,  and  high  fever.  Dry  cups,  over  the  affected  area,  and  wet 
cups  afford  marked  relief  when  applied  early  in  cases  beginning  with 
severe  pleurisy  and  edema  of  the  lungs. 

Drugs. — The  most  important  of  these  are  the  cardiac  stimulants, 
especially  strychnin,  digitalis,  nitroglycerin,  and  alcohol.  Each  should 
be  given  with  reference  to  the  effect  obtained,  and  not  by  rote.  Strychnin 
should  be  given  hypodermically  in  doses  of  gr.  1-60  to  1-20  (o.ooi — 
0.003)  every  three  hours  unless  muscular  twitching  is  produced.  Nitro- 
glycerin, gr.  i-ioo  to  1-50  (0.0005 — o.ooi),  may  be  given  when  dyspnea 
or  other  symptoms  indicate  a  disproportion  between  the  heart's  action 
and  the  arterial  tension.  Digitalis  should  be  given  in  full  doses  of  the 
infusion,  an  active  tincture,  or  fluid  extract.  Ammonium  carbonate,  gr. 
V — X  (0.3 — 0.6),  and  citrated  caffein,  gr.  ij — iij  (o.i — 0.2),  are  often  bene- 
ficial. Veratrum  viride,  once  much  in  vogue,  is  employed  by  some  phy- 
sicians, but  should  be  used  with  great  caution,  in  2  to  5  drop  doses 
of  the  tincture  only  until  the  heart's  action  has  become  normal. 

Diaphoretics  should  not,  as  a  rule,  be  employed,  although  they  have 
been  thought  to  reduce  sweating  and  prostration  during  the  crisis  if 
administered  before  it.  Alcohol  is  highly  regarded  by  some  writers.  As 
a  rule,  its  use  is  unnecessary,  if  not  injurious,  and  it  is  inferior  to  strych- 
nin, even  in  alcoholic  cases.  Quinin  is  the  safest  antipyretic.  The  coal- 
tar  antipyretics  are  unsafe,  as  a  rule. 

Creosot  carbonate  has  recently  been  employed  in  many  cases,  with 
results  which  apparently  justify  the  claim  that  it  is  a  specific.  It  im- 
mediately reduces  the  temperature,  quiets  the  cough,  and  often  produces 
an  early  termination  by  lysis  or  by  crisis  free  from  weakness  and  pros- 
tration. It  should  be  given  in  doses  of  gr.  v  (0.3),  increasing  rapidly 
to  gr.  XV  (i.o),  every  two  or  three  hours,  from  the  beginning. 

Tneaiment  of  Special  Symptoms. — Pain  must  be  relieved  at  the  onset, 
often  by  morphin  hypodermically,  and  followed  with  codein  at  frequent 
intervals.  But  the  action  of  an  opiate  must  be  watched,  lest  it  produce 
cardiac  depression.  Holt  regards  phenacetin  as  better  than  opium  for 
restlessness  and  cough  in  children.  A  single  dose  in  24  hours  is  often 
sufficient. 

Inhalations  of  oxygen  often  assist  the  patient  to  reach  the  crisis. 
It  is  administered  pure  for  1 5  minutes  at  a  time,  or,  diluted  with  atmos- 
pheric air,  for  longer  periods.    It  must  be  pure  and  fresh. 

Edema  of  the  lungs  may  be  checked  by  cupping  and  the  administration 
of  atropin,  gr.  i-ioo  (0.0005),  with  each  dose  of  strychnin,  to  check 
secretion. 

Delirium  may  be  modified  by  the  administration  of  the  bromids    in 


DIPHTHERIA  129 

full  doses,  but  morphin,  gr.  ^  to  %,  may  be  required.  Stimulation  and 
cold  sponging  often  have  a  beneficial  influence  upon  it. 

Saline  injections  have  been  employed  in  severe  cases,  and  apparently 
with  benefit,  in  carrying  the  patient  over  a  critical  period.  From  one  to 
two  pints  of  a  7  per  cent  solution  are  allowed  to  flow  by  gravity 
through  a  large  hypodermic  needle  into  the  subcutaneous  tissue. 

Serum  Treatment. — If  the  theory  be  true  that  the  crisis  announces  the 
victory  of  the  antitoxin  produced  by  the  system  over  the  toxin  of  the 
disease,  there  is  much  reason  to  hope  for  a  successful  serumtherapy. 
The  results  obtained  in  this  direction  have  been  encouraging.  The  serum 
of  Pane,  obtained  from  the  larger  animals,  is  injected  into  the  subcu- 
taneous tissue  in  the  quantity  of  from  40  to  120  c.c.  in  24  hours.  In- 
travenous injections  have  been  made  in  a  few  instances.  The  serum  of 
convalescents  has  also  been  employed. 

DIPHTHERIA. 

DIPHTHERITIS,  ANGINA  MALIGNA,,  PUTRID  SORE-THROAT. 

Definition. — An  acute  infectious  disease  occurring  sporadically  or  epi- 
demically, caused  by  the  Klebs-Loffier  bacillus,  and  attended  with  a 
fibrinous  exudate  on  the  mucous  membrane  of  the  pharynx  and  upper 
respiratory  passages  and  symptoms  of  toxemia. 

Etiology. — The  Klebs-Loffler  bacillus  is  constantly  found  in  the  pseu- 
domembranous deposit  on  the  throat,  and  is  recognized  as  the  spe- 
cific cause  of  the  disease.  Diphtheria  is  endemic  in  most  of  the  cities 
and  towns  of  the  United  States  and  frequently  becomes  epidemic  during 
the  winter  season.  Sporadic  cases  occur  and  are  often  virulent  in  char- 
acter. The  disease  is  encountered  in  all  climates  and  its  spread  is  favored 
by  the  cold  of  winter  and  spring.  It  is  highly  contagious  and  may  be 
contracted  by  direct  contact.  It  has  frequently  been  conveyed  by  kissing, 
and  physicians  have  been  repeatedl}^  inoculated  by  injudicious  attempts 
to  clear  by  suction  an  obstructed  trecheotomy  tube,  or  by  having  the 
membrane  coughed  into  their  faces  while  examining  or  treating  the 
throat.  The  infectious  agent  may  be  carried  b)^  clothing,  bedding,  hand- 
kerchiefs, drinking-cups,  hair,  shoes,  pencils,  and  other  articles  from  the 
sick-room,  but  probably  not  by  the  air  or  by  sewer-gases.  So  far  as 
known,  it  is  carried  by  pet  animals  onl)^  in  their  fur.  The  so-called 
diphtheria  of  animals  and  birds  is  generall}^  due  to  other  bacteria  than 
the  diphtheria  bacillus.  The  bacillus  is  so  tenacious  of  life  when  protected 
from  light  and  air  that  it  has  been  known  to  retain  its  virulence  for 
several  months,  and  to  remain  alive  in  the  throat  for  almost  a  year. 
It  grows  freely  in  milk,  and  cases  have  been  traced  to  this  source.  It 
may  be  carried  in  the  throat  of  a  healthy  individual  without  producing 
any  disturbance  for  days  or  weeks.  As  W.  H.  Park  remarks,  "  W^en  we 
consider  that  it  is  only  the  severe  cases  of  diphtheria  that  remain  isolated 
during  their  actual  illness,  the  wonder  is  not  that  so  many,  but  that 
so  few,  persons  contract  the  disease." 

The  bacilli  are  believed  to  enter  the  system  only  through  inhalation, 
by  being  conveyed  in  some  other  manner  to  the  mouth,  or  b}'^  the 
inoculation  of  an  abraded  surface  in  some  other  part  of  the  body. 

9 


130  PRACTICE  OF  MEDICINE 

Age  is  an  important  factor  in  susceptibility.  A  large  majority  of 
cases  occur  between  two  and  fifteen ;  the  period  of  greatest  susceptibility 
appears  to  be  between  the  third  and  tenth  years.  The  disease  seldom 
occurs  in  infants  or  in  adults  after  the  thirtieth  year,  but  A.  Jacobi 
has  seen  it  in  the  new-born  and  in  a  man  of  86  years.  Some  individuals 
and  some  families  are  undoubtedly  more  susceptible  to  infection  than 
others.  Epidemics  vary  greatly  in  severity.  Caille  emphasizes  the  im- 
portance of  enlarged  tonsils,  chronic  nasopharyngeal  catarrh,  carious 
teeth,  and  an  unhealthy  condition  of  the  mucous  membrane  of  the  mouth 
and  throat  as  predisposing  causes. 

Immunity.— ^oraQ  degree  of  natural  immunity  is  probably  possessed 
by  many  persons,  else  the  disease  would  be  much  more  prevalent  than 
it  is.  It  probably  depends  upon  the  inability  of  the  bacillus  to  pene- 
trate into  a  healthy  mucous  membrane.  An  attack  of  the  disease  confers 
immunity  for  an  indefinite,  but  probably  short,  space  of  time.  Second 
attacks  have  frequently  been  seen  after  a  few  months.  Golay  reports 
a  case  in  which  the  bacilli  were  constantly  present  in  the  throat  of  an 
individual  for  362  days,  during  which  time  he  had  three  acute  attacks. 

Bacteriology. — The  diphtheria  bacilli,  as  they  are  usually  found  in  the 
false  membrane  of  diphtheria,  are  straight  or  slightly  curved,  nonmotile 
rods  from  1.5  to  6.0/i  in  length  and  from  0.5  to  0.8/i  in  thickness,  with 
rounded  or  clubbed  extremities.  They  are  not  usually  uniformly  cylin- 
drical, but  are  thicker  at  one  end,  or  swollen  in  the  middle  and  more 
slender  at  the  ends.  They  are  sometimes  found  in  pairs,  rarely  in  chains. 
What  appear  to  be  branching  forms  are  sometimes  seen.  The  bacillus  is 
an  aerobe,  but  varies  greatly  in  morphology  and  other  qualities  under 
different  methods  of  cultivation.  It  is  very  resistant  to  extrem.e  cold, 
but  readily  succumbs  to  a  temperature  of  58°  C.  The  usual  stain  for  it 
is  Loffler's  methylene-blue  solution.  Neisser's  differential  stain  should 
be  employed  to  distinguish  the  true  bacillus  from  the  pseudobacillus. 
It  is  almost  the  rule  to  find  in  the  false  membrane  also  streptococci, 
staphylococci,  or  pneumococci.  The  streptococcus  pyogenes  is  usually 
found  in  suppurating  glands  when  they  occur  in  this  disease. 

False  JDiphtheria.—Ot\iGr  bacteria  besides  the  Klebs-Loffler  bacillus  are 
capable  of  producing  pseudomembranous  inflammation.  Some  of  these 
are  almost  constantly  to  be  found  in  the  secretions  of  the  throat,  and 
only  under  favorable  circumstances  produce  lesions  similar  to  those  of 
diphtheria.  The  streptococcus  and  pneumococcus  most  frequently  act 
in  this  capacity.  In  false  diphtheria,  these  forms  are  sometimes  found, 
but  in  many  cases  a  pseudodiphtheria  or  diphtheroid  bacillus  occurs 
which  is  different  in  morphology  and  culture  from  the  Klebs-Loffier  ba- 
cillus. 

Morbid  Anatomy. — The  distinctive  lesion  of  the  disease  is  the  pseudo- 
membrane,  which  consists  of  a  fibrin  reticulum  inclosing  in  its  meshes 
leucocytes  in  a  state  of  hyalin  degeneration,  degenerated  epithelial  cells, 
and  occasionally  a  few  erythrocytes.  The  membrane  dips  deeply  into 
the  epithelial  layers  of  the  mucous  membrane,  but  does  not  invade  the 
submucosa.  The  mucosa  undergoes  rapid  degenerative  changes  and 
necrosis.  A  change  occurs  in  the  deeper  tissues,  also,  which  is  in  part 
due  to  degeneration,  in  part  to  infiltration;  necrosis  may  occur  in  them. 
The  bacilli  are  usually  found  in  the  membrane,  and  they  alone  are  charac- 


DIPHTHERIA  131 

teristic  of  the  diphtheritic  membrane.  Other  cocci  are  generally  present. 
The  false  membrane  is  more  frequently  found  upon  the  tonsils.  It  is 
rarely  confined  to  them,  but  in  more  than  half  the  cases  it  is  limited  to 
the  tonsils  and  uvula.  It  often  spreads  from  these  to  adjacent  surfaces. 
It  may  invade,  primarily  or  secondarily,  the  pharynx,  nasal  chambers, 
larynx,  trachea,  and  bronchi,  involving  the  entire  surface,  or  pass  for- 
ward over  the  soft  palate  and  pillars  to  the  mucous  membrane  of  the 
entire  mouth ;  occasionally  even  over  the  lips  to  the  face.  The  membrane 
has  rarely  been  found  in  the  esophagus,  stomach,  rectum,  bladder,  va- 
gina and  puerperal  uterus,  and  on  the  external  genitals  of  both  sexes. 
Its  character  varies.  It  is,  as  a  rule,  thick,  tough,  and  elastic,  usually 
laminated,  rarely  thin,  but  always  firmly  adherent  except  in  the  larynx. 
It  may  be  an  eighth-inch  thick.  After  death  it  becomes  soft  and  friable. 
The  capillaries  and  smaller  blood-vessels  in  the  vicinity  show  hyalin 
degeneration. 

The  heart  is  usually  flabby,  the  right  ventricle  or  both  dilated.  The 
myocardium  generally  shows  fatty  or  other  degeneration.  There  may 
be  also  degeneration  or  necrosis  of  the  endocardium,  and  thrombi  may 
be  found  in  the  chambers.  ^ 

The  Lungs. — Bronchopneumonia  is  commonly  found.  There  may  be 
also  marked  congestion,  edema,  and  atelectasis.  Thrombi  are  sometimes 
found,  and  there  may  be  gangrene  of  the  lung.  The  bronchi  are  generally 
involved  and  may  contain  a  membranous  exudate.  The  bacilli  are  often 
found  in  greater  numbers  here  than  in  any  other  region  affected. 
Dilatation  of  the  lymph-vessels  is  also  common;  they  may  be  densely 
filled  with  lymph  and  plasma  cells.  The  cervical  glands  are  enlarged  to 
some  extent  in  almost  all  cases,  but  markedly  in  only  about  a  third  of 
the  cases  which  involve  the  throat.  The  tissues  about  the  glands  are 
sometimes  edematous,  and  the  submaxillary  gland  may  be  swollen. 

The  liver  and  spleen  show  the  usual  changes  arising  from  toxemia. 
Kidney  changes  varying  from  slight  degeneration  to  intense  acute  ne- 
phritis are  found  in  all  fatal  cases.  The  lesions  are  most  pronounced 
in  the  rapidly  fatal  cases. 

Nervous  System. — It  is  in  the  nervous  system  that  the  most  prom- 
inent results  of  toxemia  are  usually  found,  and  more  particularly  in  the 
nerve-trunks  of  the  central  system.  The  change  begins  in  the  myelin 
sheath  at  some  point  near  the  axis  cylinder,  and  gradually  extends 
around  and  along  it.  The  lesions  are  essentially  those  of  neuritis  and 
may  be  found  anywhere  in  the  nervous  system. 

Symptoms. — General. — The  period  of  incubation  varies  from  two  days 
to  a  week,  but  is  seldom  more  than  four  days.  The  initial  symptoms 
vary  remarkably  in  severity.  The  onset  is  seldom  marked  by  more  than 
slight  indisposition.  Vomiting,  rarely  a  convulsion,  may  occur  in  young 
children,  and  the  prostration  is  often  out  of  proportion  to  the  other 
indications  of  illness.  General  muscular  soreness  and  stiffness  of  the 
neck  are  occasionally  observed.  The  symptoms  are  generally  proportion- 
ate to  the  extent  of  surface  invaded  by  the  membrane,  but  the  rule  is 
not  without  many  exceptions.  In  some  cases  the  constitutional  symp- 
toms are  intense  without  recognizable  membrane-formation,  and  in 
some  of  the  most  extensively  membranous  cases  the  systemic  disturb- 
ances   are    exceptionally  sHght.    The  patient  is  generally  pale,  the  face 


132  PRACTICE  OF  MEDICINE 

often  has  an  ashen  hue.  If  a  child,  it  becomes  languid  or  fretful  and 
restless  and  it  may  complain  of  headache,  loss  of  appetite,  and  nausea. 
It  may  later  pass  into  a  stupor  or  become  delirious.  In  many  cases, 
however,  the  mind  remains  clear  throughout  the  disease,  although  se- 
vere. The  tongue  has  a  white  coat  and  the  breath  is  offensive.  There 
is  usually  an  urgent  thirst.  The  constitutional  symptoms  are  generally 
more  pronounced  in  adults  than  in  children,  although  the  membrane- 
formation  is  usually  less  extensive.  They  become  more  prominent  as 
the  disease  reaches  its  height,  and  are  especially  severe  when  necrosis 
and  sloughing  occur. 

The  temperature  is  not  usually  high.  In  the  majority  of  uncomplicated 
cases  it  does  not  reach  102°  F.  (39.0°  C.)  at  any  time,  very  often  it 
does  not  exceed  101°  F.  (38.5°  C.)  and  the  fever  may  subside  in  48  to 
7  2  hours.  Instances  of  subnormal  temperature  are  not  infrequent.  The 
pulse  is  accelerated  out  of  proportion  to  the  temperature  and  frequently 
reaches  150  or  160  in  children.  It  may  reach  180.  In  cases  character- 
ized by  great  cardiac  weakness,  however,  it  often  becomes  as  slow  as 
40  or  50. 

In  some  cases  the  disease  begins  with  early  elevation  of  temperature, 
marked  nervous  manifestations,  and  it  may  terminate  fatally  within  a 
few  days  from  the  intensity  of  the  toxemia.  Dyspnea  is  present  in  many 
cases,  particularly  when  the  larynx  is  involved ;  it  may,  however,  result 
from  disintegration  of  the  red  blood-corpuscles  by  the  toxins,  from 
degenerative  changes  in  the  heart,  or  from  a  sudden  spasm  or  paralysis 
of  the  vocal  cords. 

"  The  heart  is  probabl}^  affected  in  every  case  of  diphtheria"  (Jacobi). 
Either  tachycardia  or  bradycardia  is  a  feature  of  almost  all  severe  cases. 
A  systolic  murmur  is  heard  in  about  10  per  cent  of  cases,  usually  at 
the  apex,  and  the  pulmonic  second  sound  is  often  accentuated.  Since 
endocarditis  is  not  common,  this  sound  is  probably  due  to  relaxation. 
Cardiac  dilatation  frequently  precedes  a  fatal  issue. 

The  nervous  system  is  profoundly  affected  by  the  toxins.  This  is 
shown,  not  only  by  the  frequency  of  psychical  depression,  but  also  by 
the  development  of  paralysis  in  about  10  per  cent  of  cases.  These  are 
more  fully  considered  under  the  head  of  Complications. 

Moderate  albuminuria,  due  to  the  irritation  of  the  kidneys  by  the 
toxins,  appears  frequently  on  the  second  day  of  the  disease,  or  later,  in 
a  majority  of  cases.  Hyalin  and  granular  casts  are  often  present, 
usually  appearing  later  as  a  result  of  the  obstruction  of  respiration. 

The  cervical  glands  usually  become  enlarged,  and  the  tissues  about 
them  are  edematous.    The  voice  becomes  nasal. 

The  blood-count  reveals  moderate  leucocytosis  in  all  cases.  The 
count  of  polynuclears  and  mononuclears  is  shown  to  be  characteristic 
and  important  by  Besredka.  In  all  but  the  most  fatal  cases  the  former 
type  of  cells  is  much  increased,  while  a  decrease  in  the  mononuclears  is 
always  observed.  There  is  a  deficiency  of  red  cells  amounting  to  from 
500,000  to  2,000,000  in  the  c.mm.  and  the  hemoglobin  is  reduced  from 
12  to  25  per  cent. 

The  membrane  usually  remains  attached  for  5  or  6  days,  and,  grad- 
ually becoming  detached  around  the  edges,  soon  separates,  leaving  a  de- 
nuded surface  or  superficial  ulceration.     The  swelling  and  glandular  en- 


DIPHTHERIA  133 

largement  rapidly  subside,  but  the  convalescence  is  often  slow  and  may 
be  markedly  interrupted  by  the  most  distressing  complications. 

In  fatal  cases  the  temperature  may  subside  while  the  pulse  becomes 
more  rapid,  irregular,  and  feeble  or  extremely  slow,  50  or  less.  The 
action  of  the  kidneys  may  fail;  the  urine  becomes  scant  and  highly 
albuminous,  and  uremia  develops.  Other  cases  terminate  fatally  on 
account  of  pulmonary  edema,  collapse,  or  bronchopneumonia.  Sudden 
death  from  paralysis  of  the  heart  has  been  repeatedly  observed,  partic- 
ularly as  a  result  of  excitement  or  exertion  during  convalescence. 

Varieties  of  Diphtheria. — In  addition  to  the  symptoms  just  enumer- 
ated, others  occur  which  depend,  for  the  most  part,  upon  the  location 
of  the  disease. 

Tonsillar  or  Pharyngeal  Diphtheria. — The  first  complaint  is  usually  of 
soreness  or  dryness  of  the  throat  upon  swallowing  or  speaking.  When 
the  tonsils  are  first  affected  there  is  usually  a  slight  rise  of  temperature, 
rarely  exceeding  101°  F.  (38.5°  C).  The  tonsils  at  first  appear  slightly 
enlarged,  intensely  hyperemic,  and  on  the  surface  of  one  or  both  there 
is  one  or  more  small  patches  of  a  gi-ayish  membrane.  The  uvula,  the 
pillars,  and  the  pharynx  are  usually  congested.  If  an  examination  is 
made  only  a  few  hours  later,  the  membrane  may  be  found  to  have  spread 
over  the  entire  surface  of  the  tonsils,  and  new  patches  may  have  developed 
on  adjacent  surfaces.  Swallowing  and  speaking  rapidly  become  more 
difficult  and  painful,  and  the  symptoms  of  prostration  more  pronounced. 
The  cervical  glands  are  enlarged  and  sensitive,  but  less  so  than  in  ton- 
silitis.  In  other  cases  the  exudate  remains  confined  to  the  tonsils  or 
spreads  to  but  a  limited  area  of  the  adjacent  mucous  membrane;  little 
or  no  pain  is  complained  of  and  the  adenitis  is  slight. 

Maligjtant  cases  not  infrequently  occur  in  which  the  extension  of  the 
membrane  is  extremely  rapid  and  the  constitutional  disturbance  most 
profound.  Within  the  first  24  hours  the  entire  surface  of  the  tonsils, 
the  sides  of  the  pharynx,  the  uvula,  and  soft  palate  are  covered  with  a 
heavy  exudate,  and  the  glands  of  the  neck  become  enormously  enlarged. 
The  temperature  may  be  but  slightly  elevated;  it  may  even  be  sub- 
normal, but  the  heart's  action  is  rapid  and  feeble  or  slow  and  irregular. 
Stupor  develops  and  the  case  terminates  fatally  within  three  or  four 
days  from  toxemia.  In  other  malignant  cases  the  membrane,  although 
not  extensive  in  its  invasion,  has  a  foul,  necrotic  appearance,  giving 
the  breath  a  sweetish,  fetid  odor.  The  adjacent  tissues  for  a  consider- 
able distance  may  be  involved  in  the  necrosis,  and  symptoms  of  sepsis 
often  supervene.  The  tongue  becomes  dry,  the  temperature  runs  up  to 
104°  or  105  °F.  (40°— 40.5°  C),  the  pulse  is  rapid  and  feeble,  the  ex- 
tremities become  cold.  Death  may  result  from  exhaustion  or  from  the 
supervention  of  bronchopneumonia. 

Atypical  cases  are  not  infrequent,  in  which:  (i)  The  mucous  mem- 
branes of  the  throat  are  intensely  hj^peremic  and  edematous,  but  no 
pseudomembrane  is  formed.  (2)  The  membrane  may  be  punctate  in 
form,  remaining  confined  to  small,  isolated  areas.  In  either  of  these 
forms  the  exudation  may  rapidly  form  or  suddenly  assume  an  active 
growth  and  spread  with  great  rapidity  into  the  nares  or  larynx.  (3) 
The  exudate  may  be  soft  and  creamy  or  pultaceous  in  character. 

Laryngeal  Diphtheria. — WTien  primarily  affecting  the  larynx  the  dis- 


134  PRACTICE  OF  MEDICINE 

ease  begins  with  hoarseness  and  a  harsh,  croupy  cough.  By  the  second 
or  third  day  there  may  be  complete  aphonia,  stridulous  respiration,  a 
shrill,  whistling  cough,  and  the  most  alarming  dyspnea,  and  cyanosis, 
with  great  restlessness.  When  the  laryngeal  involvement  is  a  result  of  the 
extension  of  the  disease  from  the  pharynx,  these  symptoms  are  added 
to  those  already  described.  As  the  disease  advances,  the  signs  of  ste- 
nosis become  extreme.  The  accessory  muscles  of  respiration  are  called 
into  play.  Rigidity  of  the  sternomastoid  muscle  is  an  early  indication 
of  it  (McCollom).  The  nostrils  vibrate,  the  supraclavicular  and  inter- 
costal spaces  sink  with  each  inspiration,  cyanosis  becomes  extreme. 
The  child  sits  up  and  gasps  for  breath  until  exhausted  or  overcome  by 
the  suffocation,  then  falls  back,  possibly  to  doze  for  a  moment,  but  not 
to  find  relief.  The  detachment  of  a  fragment  of  the  membrane  by  cough- 
ing affords  a  short  respite,  but  the  membrane  is  soon  replaced  and  the 
dyspnea  returns.  The  constitutional  symptoms  soon  become  intensified. 
The  temperature  often  rises  to  103°  F.  (39.5°  C.)  and  the  action  of 
the  heart  may  suddenly  cease.  The  patient  may  sink  into  a  coma  or 
die  of  exhaustion.  Bronchopneumonia  follows  this  type  of  the  disease 
oftener  than  any  other.  Fortunately,  under  present  methods  of  treat- 
ment these  extreme  cases  are  seldom  encountered. 

Nasal  diphtheria  may  develop  primarily  or  as  an  extension  from  the 
disease  of  the  pharynx.  It  is  much  more  frequent  in  children  than  in 
adults.  It  is  usually  characterized  by  mixed  infection.  The  initial  sympn 
toms  may  be  those  of  an  acute  nasal  catarrh.  The  nostrils  become 
obstructed  and  a  thin,  mucopurulent,  sometimes  sanguinolent,  irritating 
fluid  flows  from  them.  Sneezing  is  caused  by  the  irritation,  and  the 
lips  become  excoriated.  Distinct  enlargement  of  the  glands  at  the 
angle  of  the  jaw  and  of  the  submaxillary  glands  is  developed  early. 
In  one  group  of  cases  the  nostrils  become  completely  filled  with  a  thick 
membranous  formation  (fibrinous  rhinitis),  while  in  another  class  they 
are  obstructed  by  the  intense  hyperemia  and  swelling,  without  an  ex- 
udate. In  the  former  class  the  constitutional  disturbances  are  often 
slight  and  recovery  occurs  in  the  usual  time,  while  in  the  other  class 
the  system  may  become  charged  with  the  toxins  and  the  disease  may 
assume  a  malignant  character.  The  bacilli  are  usually  numerous  in  the 
membrane  or  discharge,  and  great  numbers  of  other  micro-organisms 
are  also  found,  particularly  streptococci  and  staphylococci;  sometimes 
the  yellow  sarcina,  the  bacilli  subtilis  and  proteus  are  present.  The 
inflammation  frequently  extends  to  the  Eustachian  tube  and  middle  ear 
or  to  the  antrum,  occasionally  through  the  lachrymal  ducts  to  the  con- 
junctivae. 

Diphtheria  of  Other  Parts. — Primary  diphtheria  very  rarely  attacks 
the  conjunctiva,  producing  a  catarrhal  or  membranous  inflammation. 
The  globe  is  sometimes  perforated  in  a  single  day.  The  presence  of  the 
Klebs-Loffler  bacillus  establishes  the  identity  of  the  disease.  This  organ- 
ism may  alone  be  present,  or  the  infection  may  be  of  a  mixed  character. 
The  external  auditory  meatus  is  sometimes  the  seat  of  the  disease, 
which  is  generally  a  secondary  involvement  from  the  middle  ear. 

Diphtheria  of  the  skin  is  generally  confined  to  the  regions  about  the 
mouth,  but  it  may  be  conveyed  by  the  fingers  of  the  child  to  more 
remote  parts,  particularly  to  the  external  genitalia  and  the  anal  region. 


DIPHTHERIA 


135 


Wounds  are  occasionally  infected,  producing  either  a  superficial  inflam- 
mation, occasionally  accompanied  by  necrosis,  or  the  formation  of  a 
false  membrane.  Thee  onstitutional  symptoms  of  wound  diphtheria  are 
usually  slight,  but  paralysis  sometimes  follows  it. 

Complicaiions  and  SequelcB. — Hemorrhage  sometimes  occurs  as  a  re- 
sult of  ulceration  in  the  nose  or  throat,  especially  in  the  nasal  form 
of  the  disease.  It  is  encountered  also  in  malignant  cases,  probably  as 
a  result  of  profound  blood  changes,  in  the  nature  of  toxemia. 

Pneumonia. — Bronchitis  frequently  develops  as  early  as  the  first  or 
second  day  of  the  disease,  especially  in  laryngeal  cases.  It  may  be 
delayed  until  after  the  beginning  of  convalescence.  Pulmonary  collapse 
or  bronchopneumonia  sometimes  results  from  it.  The  diagnosis  is 
often  difficult,  for  all  of  the  usual  signs  may  be  obscured  by  the  great 
restriction  of  respiration,  deficient  expansion  of  the  chest,  and  the  loud 
noises  produced  in  the  larynx.  Aii  increase  of  temperature,  accompanied 
by  marked  rapidity  of  breathing,  usually  indicates  the  condition.  Lo- 
bar pneumonia  is  rare.  An  aspiration  pneumonia,  which  may  ter- 
minate in  gangrene  of  the  lung,  may  be  induced  in  cases  attended  with 
extensive  sloughing  or  a  soft  pultaceous  membrane. 

Heart-failure  is  one  of  the  most  dangerous  complications.  It  is  most 
likely  to  develop  after  the  membrane  has  become  detached,  and  the 
danger  continues  great  from  the  third  to  the  fifth  week.  Cases  in  which 
the  appearance  is  most  indicative  of  anemia  are  most  liable  to  it.  The 
asthenic  condition  of  the  heart  may  be  recognized  by  the  slowness, 
irregularity,  and  weakness  of  the  pulse,  as  well  as  by  cyanosis  and  oc- 
casional attacks  of  syncope.  In  some  cases  apparently  progressing 
favorably  such  slight  exertion  as  sitting  up  or  vomiting  or  the  excite- 
ment occasioned  by  the  visit  of  a  friend  causes  the  heart  to  become 
extremely  erratic  in  its  action  or  to  suddenly  stop.  Similar  accidents 
may  happen  even  during  the  first  week.  Hibbard  found  degenerative 
changes  in  the  vagus  in  all  fatal  cases  of  heart-failure. 

Paralyses  (postdiphtheritic  paralyses),  due  to  toxic  neuritis,  occur 
in  about  i  o  per  cent  of  cases.  They  generally  develop  during  the  second 
or  third  week,  but  may  occur  as  early  as  the  seventh  day  or  as  late 
as  the  sixth  week.  They  may  be  either  local  or  multiple,  unilateral 
or  symmetrical.  They  follow  the  mildest  attacks  with  apparently  as 
much  certainty  as  the  most  severe,  but  are  more  frequent  in  adults  than 
in  children.  The  symptoms  produced  in  the  multiple  form  are  exceed- 
ingly variable  in  character,  depending  upon  the  nerves  aff"ected.  One  of 
the  most  common  local  paralyses  is  that  of  the  uvula.  This  is  attended 
with  difficulty  in  swallowing,  regurgitation  of  food  through  the  nose, 
and  a  nasal  tone  of  the  voice.  The  palate  is  relaxed,  and  the  uvula 
appears  elongated  and  dependent.  The  constrictor  muscles  of  the  phar- 
ynx are  sometimes  involved  in  the  paralysis.  Either  the  extrinsic  or 
the  intrinsic  muscles  of  the  eye  may  be  paralyzed,  causing  ptosis,  stra- 
bismus, or  a  loss  of  the  power  of  accommodation.  Facial  paralysis 
sometimes  occurs  and  may  prove  to  be  persistent.  In  some  of  these 
cases  a  paraplegia  or  a  paralysis  of  the  arms  is  associated  with  that 
of  the  muscles  of  the  eye  or  of  the  throat.  The  termination  is  usually 
in  recovery,  except  when  the  heart  or  the  muscles  of  respiration  become 
involved.     One  or  both  of  either  the  upper  or  lower  extremities  may 


136  PRACTICE  OF  MEDICINE 

become  partially  or  completely  paralyzed,  without  the  involvement  of 
other  parts.  A  solitary  paralysis  of  the  bladder  has  been  recorded  in 
one  instance. 

Nephritis. — Albuminuria  is  a  constant  feature  of  severe  cases.  The 
quantity  of  albumin  present  may  be  a  mere  trace  and  is  probably  due 
to  the  irritation  of  the  kidneys  by  the  toxins  or  to  the  fever.  Actual 
nephritis  is  not  a  frequent  complication.  When  present,  it  is  indicated 
by  a  marked  reduction  in  the  quantity  of  urine  voided,  rarely  by  total 
suppression,  a  large  percentage  of  albumin,  and  epithelial  and  blood 
casts.  Edema  is  seldom  a  feature  of  diphtheritic  nephritis.  The  prognosis 
is  generally  favorable. 

Septic  infection  not  infrequently  occurs  in  the  more  malignant  cases, 
as  a  result  of  extensive  necrosis  and  sloughing  of  tissues.  A  septic  in- 
fection of  the  joints  and  other  parts  is  sometimes  observed. 

Cutaneous  eruptio?ts  are  sometimes  observed.  Erythema  and  urticaria 
are  the  more  frequent  types.  Several  cases  of  gangrenous  stomatitis 
and  vulvitis  (noma)  have  been  reported  in  which  the  diphtheria  bacillus 
was  found. 

Diagnosis. — The  discovery  of  the  Klebs-L5ffler  bacillus  is  the  only 
means  of  making  an  absolutely  positive  diagnosis  of  the  disease.  When 
this  is  found  in  a  throat  that  is  inflamed,  whether  or  not  a  membranous 
formation  is  present,  it  indicates  in  almost  every  case  that  the  individual 
is  suffering  from  diphtheria,  and  even  more  positively  that  he  may 
prove  a  source  of  infection  to  other  persons.  Diphtheria  does  not  exist 
without  the  bacilli,  but  these  may  be  overlooked  for  a  time,  and  it 
should  be  borne  in  mind  that  the  bacilli  have  been  repeatedly  found  in 
the  throats  of  healthy  children  and  adults.  There  is  no  other  disease 
in  which  bacteriological  examination  is  so  important.  The  health  de- 
partments of  all  the  larger  cities  and  of  many  villages  recognize  this 
fact  and  provide  for  the  examination  free  of  charge  of  all  specimens 
submitted.  In  most  places  an  examination  of  the  secretions  from  the 
throats  of  all  suspicious  cases,  by  an  official  bacteriologist,  is  required 
by  law.  The  examination  may  be  made  directly  from  the  throat,  but 
it  is  ordinarily  so  diflEicult  and  requires  so  much  experience  and  skill 
that  it  is  customary  to  make  it  from  a  culture. 

The  throat  appearances  in  diphtheria  are  more  or  less  typical  and 
are  usually  sufficient  to  establish  a  tentative  diagnosis  when  accom- 
panied by  the  usual  symptoms,  and  more  particularly  when  the  disease 
is  epidemic  in  the  locality.  The  diphtheritic  membrane  is  gray  or  yel- 
lowish gray  in  color.  It  does  not  rest  lightly  upon  the  surface,  but 
has  the  appearance  of  having  grown  from  the  mucous  membrane.  It 
cannot  be  detached  by  ordinary  rubbing  with  a  swab,  while  the  mem- 
branous formations  produced  by  other  bacteria,  with  the  exception  of 
Vincent's  bacillus,  are  generally  removed  without  much  difficulty.  (For- 
cible removal  should  not  be  attempted,  on  account  of  the  danger  of 
increasing  the  infection.)  The  extent  to  which  the  surfaces  are  ihvaded 
by  the  disease  is  also  of  value.  As  a  rule,  the  more  extensive  its  for- 
mation, particularly  if  it  cover  the  entire  surface  of  the  tonsils  and  begin 
to  invade  other  regions,  the  more  positive  is  the  diagnosis  of  diphtheria. 
The  appearance  of  membrane  in  the  nose  is  almost  invariably  due  to 
this  disease. 


DIPHTHERIA 


137 


The  hyperemia  of  the  tissues  surrounding  a  membrane-formation  is 
seldom,  if  ever,  so  intense  in  any  other  condition  as  it  is  in  diphtheria. 
An  intense  hyperemia  of  the  throat  without  discoverable  membrane 
should  be  regarded  as  diphtheritic  until  the  presence  or  absence  of  the 
bacillus  can  be  determined.  The  absence  of  such  hyperemia  strongly 
indicates  the  nondiphtheritic  character  of  a  membranous  formation,  but 
should  not  be  too  implicitly  relied  upon.  Paralysis  following  an  inflam- 
matory condition  of  the  throat,  with  or  without  membrane,  is  usually 
proof  that  the  case  was  one  of  diphtheria,  although  cases  have  occurred 
in  which  the  Klebs-Loffler  bacillus  had  not  been  discovered. 

The  symptoms  presented  by  the  patient  are  also  of  value.  In  many 
cases  the  mild  fever,  rapid  pulse,  and  great  prostration,  taken  in  con- 
nection with  the  throat  symptoms,  leave  no  justifiable  doubt  of  the 
diagnosis.  A  history  of  exposure  may  be  of  great  value  in  making  an 
early  diagnosis.  It  is  very  often  expedient  and  sometimes  imperative  to 
make  a  positive  diagnosis  from  the  clinical  manifestations,  and  not  to 
delay  the  treatment  until  a  bacteriological  examination  can  be  made. 

Prognosis. — The  physician  is  never  justified  in  pronouncing  an  un- 
qualifiedly favorable  prognosis  in  this  disease.  The  mortality  has  been 
reduced  since  the  introduction  of  the  serum  treatment  from  over  40 
per  cent  to  less  than  i  o  per  cent,  but  epidemics  diff'er  greatly  in  severity, 
and  there  is  no  means  of  foretelling  the  course  of  an  individual  case. 
The  disease  is  not  always  less  severe  in  robust  children,  but  convalescence 
is  usually  more  rapid  and  more  complete.  The  younger  the  child,  as  a 
rule,  the  more  unfavorable  is  the  outlook.  The  highest  mortality  is 
seen  between  the  second  and  sixth  years.  Unusually  extensive  membrane- 
formation  reduces  the  chances  of  recovery.  Laryngeal  diphtheria  is  al- 
ways extremely  dangerous.  In  the  nasal  form  the  cases  accompanied 
by  a  sanguinolent  discharge  without  membrane  are  the  most  unfavorable. 
Extreme  adenitis  is  unfavorable.  The  presence  of  a  mixed  infection  always 
increases  the  gravity  of  the  case.  Streptococci  are  particularly  dangerous, 
by  increasing  the  liability  to  sepsis.  Absence  of  polynuclear  leucocytosis 
was  noted  by  Besredka  only  in  fatal  cases.  Weakness  and  irregularity 
of  the  pulse  are  of  evil  import.  A  rapid  pulse  with  low  tem.perature  is 
equally  grave.  The  fatal  termination  of  a  case  may  be  due  to  paralysis 
of  the  heart,  pulmonary  collapse,  bronchopneumonia,  general  sepsis,  or 
toxemia.  The  mortality  independently  of  such  complications  depends 
almost  as  much  on  the  promptness  with  which  the  serum  treatment  is 
instituted  as  upon  the  type  of  the  disease.  Malignant  cases  are  now 
and  then  encountered,  however,  which  run  a  rapidly  fatal  course  under 
the  most  careful  and  skillful  treatment.  Serious,  even  fatal,  accidents 
may  occur  as  late  as  the  fifth  or  sixth  week.  The  danger  of  paralysis 
is  not  passed  for  at  least  two  months,  but  paralysis  usually  ends  in  com- 
plete recovery. 

Prophylaxis. — The  patient  should  be  isolated  in  a  room  from  which 
all  unnecessary  furniture,  carpets,  and  hangings  have  been  removed. 
Thorough  ventilation  and  a  uniform  temperature  of  about  70° F.  (21° 
C.)  should  be  maintained.  The  atmosphere  should  be  kept  moist  by 
steam  generated  from  a  suitable  vessel  in  the  room.  The  vapor  of 
turpentine,  carbolic  acid,  or  benzoin  is  thought  to  be  beneficial.  A  special 
nurse  should  be  in  charge,  and  she  should  neither  mingle  with  the  other 


X3S  PRACTICE  OF  MEDICINE 

members  of  the  family  nor  permit  them  to  enter  the  sick-chamber.  The 
physician  should  exercise  the  same  precautions  in  his  visits  as  in  other 
contagious  diseases,  wearing  a  gown  and  cap  and  disinfecting  his  hands 
and  face  after  leaving  the  room.  The  child  should  expectorate  into  a 
vessel  containing  a  strong  disinfectant  solution  (corrosive  sublimate 
I  :5oo)  or  upon  patches  of  muslin  that  can  be  immediately  burned. 
Infection  from  the  secretions  of  the  throat  is  possible  for  a  month  or 
longer  in  some  cases,  hence  isolation  should  be  maintained  until  bacteri- 
ological examination  no  longer  shows  the  presence  of  bacilli.  It  is  no 
less  important  to  isolate  mild  cases  and  those  in  which  the  diagnosis  is 
for  the  time  uncertain.  It  is  good  practice  to  separate  all  cases  of  sore 
throat  from  the  other  members  of  the  family,  even  when  the  case  is  not 
regarded  as  diphtheritic.  The  members  of  the  family  who  have  been  ex- 
posed to  the  contagion  should  be  kept  at  home,  and,  together  with 
those  who  will  come  into  contact  with  the  case,  may  be  still  further 
protected  by  the  administration  of  a  prophylactic  injection  of  from  200 
to  1,000  units  of  antitoxin.  This  will  protect  for  about  two  weeks, 
when  it  should  be  repeated.  The  nurse  and  attendants  should  gargle 
their  throats  several  times  a  day  with  an  antiseptic  solution,  preferably 
one  containing  i  :  10,000  of  corrosive  sublimate.  After  the  recovery  of 
the  patient  the  premises  should  be  thoroughly  disinfected,  as  after  other 
infectious  diseases. 

Treatment — General  Management. — The  diet  of  the  patient  should  be 
liquid  in  character — milk,  broths,  soups,  albumen-water,  and  ice-cream, 
with  an  abundance  of  cold  water.  Holt  recommends  that  nursing 
infants  be  fed  the  milk  obtained  from  the  mother's  breast  by  means  of 
a  breast-pump;  they  should  not  be  put  to  the  breast.  Forced  feed- 
ing by  means  of  a  soft  tube  passed  through  the  mouth  or  nose  must  be 
practiced  when,  in  the  later  stages  of  the  disease,  the  patient  refuses 
nourishment  or  when  the  muscles  of  deglutition  have  been  paralyzed. 
Every  measure  for  the  support  of  the  patient's  strength  should  be 
adopted  in  the  beginning.  Brandy  (from  i  to  6  ounces  in  24  hours) 
and  strychnin,  gr.  i-ioo  to  1-40  (0.0006 — 0.0016),  t.  i.  d.  or  oftener, 
should  be  administered  as  soon  as  asthenia  becomes  apparent.  When 
the  heart's  action  is  rapid,  and  when  it  becomes  weak  or  irregular, 
cafifein  or  digitalis  in  small  doses  should  be  given  in  addition  to  the 
strychnin.  The  tincture  of  strophanthus  (gtt.  ij  to  v)  probably  acts 
more  promptly  than  digitalis.  When  syncope  develops,  ammonium  car- 
bonate and  camphor  or  musk  are  indicated.  When  heart-failure  threatens, 
the  patient  should  be  kept  absolutely  quiet.  It  is  safer  in  this  con- 
dition to  secure  rest  by  the  hypodermic  administration  of  morphin  every 
few  hours,  in  sufficiently  large  doses  to  keep  the  patient  drowsy.  Paral- 
ysis of  respiration  may  be  so  sudden  in  its  onset  that  nothing  can  be 
done,  but  in  a  few  instances  several  days  of  persistent  treatment,  con- 
sisting of  the  administration  of  strychnin  in  full  doses  for  the  age,  at 
short  intervals,  the  application  of  the  galvanic  and  faradic  currents, 
and  artificial  respiration  when  occasion  required,  have  been  rewarded 
with  the  recovery  of  the  patient. 

The  internal  administration  of  remedies  for  the  purpose  of  antag- 
onizing the  disease  is  of  doubtful  utility.  A.  Jacobi  and  others  highly 
recommend  the  administration  of  mercury,   preferably  the  bichlorid  in 


DIPHTHERIA 


139 


small  doses,  gr.  1-60  (o.ooi),  often  repeated.  It  should  be  given  in 
a  small  quantity  of  water.  Some  writers  prefer  calomel,  gr.  y^  (0.008), 
dropped  upon  the  tongue  without  water.  Pilocarpin  is  thought  to 
hasten  the  elimination  of  the  toxins,  but  is  seldom  employed.  Large 
doses  of  the  tincture  of  the  chlorid  of  iron,  quinin,  and  a  host  of  other 
probably  useless  remedies  are  employed  by  many  physicians.  Emetics 
are  sometimes  given  to  strong,  vigorous  children  to  assist  in  the  re- 
moval of  the  membrane,  particularly  in  laryngeal  cases,  when  a  flapping 
sound  indicates  that  it  has  become  partially  detached,  or  when  suffoca- 
tion threatens.  Antipyretics  are  seldom  required,  and  those  of  the  coal- 
tar  group  should  not,  as  a  rule,  be  employed.  The  temperature  may 
be  more  safely  reduced  by  cold  sponging. 

The  complications  are  treated  in  the  same  manner  as  if  they  were 
independent  affections  in  a  debilitated  patient ;  special  methods  are  there- 
fore to  be  adopted  for  bronchitis,  pneumonia,  nephritis,  otitis,  and  other 
affections. 

Local  Treatment. — Local  measures  are  less  relied  upon  than  they  were 
before  the  introduction  of  antitoxin ;  possibly  they  are  too  much  neglected. 
They  should  be  employed  with  a  view  to  cleanliness  and  the  prevention 
of  such  complications  as  aspiration  pneumonia  or  involvement  of  the 
larynx,  rather  than  with  a  view  to  overcoming  the  disease.  In  very 
young  or  nervous  children,  when  it  is  apparent  that  more  worry  and 
exhaustion  is  produced  by  persistence  in  local  applications  than  is  com- 
pensated for  by  any  possible  benefit,  it  is  often  wise  to  omit  all  local 
applications. 

Numerous  antiseptic  solutions  have  been  recommended  for  use  by 
means  of  a  cotton  swab,  spray,  or  irrigation.  The  last  method  is  usually 
preferred  in  nasal  diphtheria.  For  swabbing,  the  solutions  most  used 
are  :  Mercuric  chlorid  (i  :iooo),  hydrogen  peroxid  (i  15),  and  Loffler*s 
solution  (menthol,  10  grams,  dissolved  in  sufficient  toluol  to  make  36 
c.c. ;  liquor  ferri  sesquichloratis,  4  c.c. ;  and  absolute  alcohol,  60  c.c).  For 
irrigation  the  solutions  should  be  much  diluted,  or  less  irritating  so- 
lutions, as  Seller's  alkaline  antiseptic  solution  or  boric  acid,  may  be 
employed  in  large  quantity.  Nasal  hemorrhage  sometimes  prevents  ir- 
rigation for  a  time,  or  astringent  solutions  of  alum  or  of  the  chlorid 
or  subsulphate  of  iron  (Monsel's  solution)  may  be  employed.  It  is 
claimed  for  aqueous  solutions  of  the  various  preparations  of  papaya 
and  trypsin  that  they  dissolve  the  diphtheritic  membrane.  A  solution 
of  lactic  acid  is  still  employed  by  some  physicians,  although  it  proba- 
bly has  no  specific  action. 

Antitoxin  Treatment— The  diphtheria  antitoxin  should  be  adminis- 
tered at  the  earliest  possible  moment,  for  the  results  are  better  in  pro- 
portion to  the  promptness  with  which  the  treatment  is  instituted. 
Statistics  show  that  the  mortality  is  three  times  as  great  when  the 
treatment  is  begun  on  the  third  day,  and  five  times  as  great  when  it 
is  begun  on  the  fifth  day,  as  when  on  the  first.  It  should  be  given  in 
all  forms  of  the  disease,  and  in  sufficient  quantity  to  subdue  the  action 
of  the  toxin.  It  is  only  in  the  mildest  cases  that  the  physician  is  justi- 
fied in  waiting  for  the  result  of  the  bacteriological  examination.  If  the 
case  appears  at  all  severe,  the  injection  should  be  given  at  once,  for  it 
is  better  to  err  on  the  safe  side,  and  no  harm  can  be  done  if  the  disease 


I40  PRACTICE  OF    MEDICINE 

proves  not  to  be  diphtheria.  Unfortunately,  a  time  is  reached  in  every 
severe  case  after  which  the  use  of  the  serum  is  of  comparatively  httle 
benefit.  This  time  limit  may  be  three  or  four  days,  or  it  may  be  only  six 
or  eight  hours,  and  we  have  no  means  of  determining  which  it  will  be 
in  any  case.  The  dose  of  antitoxin  is  measured  in  units.  Each  unit 
represents  the  quantity  required  to  counteract  ten  times  the  minimum 
dose  of  diphtheria  toxin  necessary  to  kill  a  guinea-pig  weighing  250 
grams.  It  is  not  possible  to  determine  the  quantity  of  toxin  that  is 
to  be  antagonized  in  a  case  of  diphtheria  affecting  a  human  being,  hence 
the  quantity  to  be  administered  must  be  determined  by  the  effect  that 
is  produced.  The  syringe  should  be  large  enough  to  hold  the  entire 
quantity  for  one  injection,  and  it  should  be  so  constructed  that  it  can  be 
thoroughly  sterilized  by  boiling  in  a  5  per  cent  solution  of  carbolic 
acid  before  each  injection.  The  serum  is  usually  injected  into  the  cellular 
tissue  of  the  loin  or  gluteal  region.  From  1,500  to  2,000  units  are  gener- 
ally given  as  the  first  dose  in  an  ordinary  case,  except  in  an  infant, 
when  from  500  to  1,000  units  may  be  sufficient.  If  the  case  is  one  of 
unusual  severity,  or  if  it  be  accom.panied  by  signs  of  laryngeal  stenosis, 
from  3,000  to  5,000  should  be  given  at  the  outset.  The  beneficial  effects— 
an  amelioration  of  all  the  symptoms,  including  a  reduction  of  tempera- 
ture and  pulse-rate— are  usually  apparent  within  a  few  hours.  If  after 
ten  or  twelve  hours  there  is  no  distinct  improvement,  or  if  the  membrane 
is  found  to  have  invaded  new  areas,  the  injection  should  be  repeated, 
and  as  many  subsequent  doses  may  be  given  as  the  case  demands. 
It  is  seldom  that  more  than  three  injections  are  required  in  a  case  in 
which  the  treatment  has  been  instituted  early. 

The  serum  treatment  is  never  more  imperative!}-  demanded  at  the 
earliest  moment  than  in  laryngeal  diphtheria.  Here  it  should  be  em- 
ployed at  the  first  evidence  of  inspiratory  or  expiratory  obstruction, 
even  when  no  membrane  can  be  seen. 

The  only  outward  effects  of  the  antitoxin  treatment  are  :  an  immediate 
rise  of  the  temperature  in  a  few  cases,  a  cutaneous  eruption,  or  the 
formation  of  an  abscess  at  the  point  of  injection.  In  from  5  to  20  per 
cent  of  cases  there  is  an  eruption  of  urticaria  affecting  the  skin  immedi- 
ately around  the  needle  wound,  or  rarely  spreading  more  or  less  generally 
over  the  entire  body.  This  disappears  within  a  few  days.  Sometimes, 
when  the  eruption  is  general,  it  resembles  that  of  scarlatina  or  measles. 
It  may  appear  as  early  as  the  second  day  or  as  late  as  the  fifteenth ; 
it  may  be  accompanied  with  fever  and  pain  in  the  joints  for  two  or  three 
days,  and  is  often  followed  by  a  profuse  desquamation. 

The  antitoxin  treatment  is  of  benefit  only  in  true  diphtheria.  Its 
action  is  limited  to  the  neutrahzing  or  antagonizing  of  the  toxin  pro- 
duced by  the  Klebs-Loffier  bacillus,  and  it  is  absolutely  useless  in  strep- 
tococcous  or  other  forms  of  infection.  If  after  the  first  injection  the 
bacteriological  examination  proves  to  be  negative,  the  dose  should  not 
ordinarily  be  repeated.  But  in  a  severe  case,  and  particularly  if  benefit 
has  followed  the  first  dose,  it  is  better  to  repeat  the  dose  on  the  sup- 
position that  some  unavoidable  accident  has  prevented  the  discovery 
of  the  bacillus,  a  supposition  that  not  infrequently  proves  correct. 

Treatment  of  Laryngeal  Diphtheria. — In  addition  to  the  methods  that 
have  been  described,  some  writers  advocate  the  inhalation  of  the  fumes 


DIPHTHERIA  i^i 

of  subliming  calomel,  produced  by  dropping  about  20  grains  of  the 
drug  on  hot  coals  if  a  special  apparatus  is  not  at  hand.  Inhalations 
of  steam,  alone  or  with  the  addition  of  such  volatile  substances  as  ben-^ 
zoin,  turpentine,  carbolic  acid,  or  eucalyptol,  are  undoubtedly  beneficial. 
They  are  administered  by  erecting  an  improvised  tent,  for  which  a  sheet 
or  blanket  will  answer,  over  the  child.  Steam  may  be  generated  by 
slowly  pouring  water  on  a  heated  brick  or  iron  at  the  side  of  the  tent. 
The  calomel  fumes  are  not  thought  to  exert  any  action  upon  the  bacillus, 
but  only  to  favor  the  detachment  of  the  membrane,  and  should  not  be 
used  too  freely. 

Intubation. — If  the  methods  that  have  been  described  do  not  aliford 
relief,  intubation  of  the  larynx  may  become  necessary.  It  should  not  be 
too  long  delayed,  but,  on  the  other  hand,  it  should  not  be  too  readily 
resorted  to,  for  the  introduction  of  the  tube  in  no  way  limits  the  ex- 
tension of  the  disease,  and  if  in  any  manner  an  abrasion  is  produced 
by  the  introduction  of  the  tube,  an  additional  point  for  infection  is  es- 
tablished. As  a  rule,  frequent  or  persistent  attacks  of  cyanosis  indicate 
the  necessity  for  a  resort  to  intubation.  The  intubation  outfit  consists 
of  a  set  of  gold-plated  or  hard-rubber  tubes  of  different  sizes,  a  holder 
for  their  insertion,  and  an  extractor.  The  mouth  of  the  child  is  held 
open  by  a  small  gag  and  the  tube,  grasped  with  the  holder,  is  guided 
back  over  the  epiglottis  by  the  finger  of  the  operator  and  gently  passed 
into  the  larynx.  The  instrument  may  sometimes  be  worn  for  several 
days.  If  no  accident  happen,  it  should  be  allowed  to  remain  for  five  or 
seven  days  from  the  beginning  of  the  stenosis;  but  if  it  becomes  ob- 
structed, it  must  be  immediately  withdrawn,  cleansed  and  replaced  with 
as  little  delay  as  possible.  The  tube  is  sometimes  coughed  out  of  place 
and  may  pass  into  the  esophagus.  It  must  then  be  withdrawn  by  means 
of  a  thread  which  is  always  attached  to  it.  Some  children  are  able 
to  take  fluid,  or,  better,  semi-fluid  nourishment,  while  the  tube  is  in  place. 
To  attempt  this,  they  should  be  held  face  downward,  or  with  the  body 
inverted.  Occasionally  a  child  can  drink  in  the  ordinary  way,  but  it  is 
generally  safer  to  use  a  tube.  This  failing,  the  food  must  be  introduced 
through  a  small,  soft  stomach-tube  passed  through  the  mouth  or  nose. 
McCollom  objects  to  nasal  feeding,  on  the  ground  that  it  favors  infection 
of  the  middle  ear.  The  atmosphere  of  the  room  should  be  heavily  im- 
pregnated with  moisture  while  the  child  wears  the  tube. 

Tracheotomy  is  now  seldom  resorted  to  until  intubation  has  failed 
to  afford  relief,  or  until  the  membrane  has  extended  into  the  trachea 
and  relief  is  no  longer  to  be  expected  from  intubation.  In  country  prac- 
tice, where  the  physician  cannot  respond  promptly  in  the  event  of  an 
obstructed  tube,  the  operation  may  be  deemed  a  safer  procedure.  Un- 
fortunately, the  benefit  to  be  hoped  for  from  tracheotomy  in  many  of 
these  cases  is  but  temporary,  on  account  of  the  extreme  growth  of  mem- 
brane or  the  development  of  such  complications  as  edema  of  the  lungs  or 
bronchopneumonia. 

DIPHTHEROID. 

PSEUDODIPHTHERIA,    MEMBRANOUS  CROUP,    StREPTOCOCCOUS  DIPHTHERIA. 

Definiiion. — An  acute  infection,  or  group  of  infections,  closely  resem- 
bhng  diphtheria  in  local  and  general  symptomatology,  but  distinguished 
from  it  by  the  absence  of  the  Klebs-Loffler  bacillus. 


142  PRACTICE  OF  MEDICINE 

Etiology. — The  afifection  is  generally  caused  by  the  streptococcus  py- 
ogenes alone  or  in  association  with  other  bacteria.  The  pseudo-diph- 
theria bacillus  may  be  present,  but  it  is  not  of  known  etiological  im- 
portance. One  of  the  most  important,  perhaps,  is  the  bacillus  of 
sputum  septicemia.  The  affection  most  frequently  occurs  as  a  compli- 
cation of  the  acute  infectious  diseases,  notably  scarlet  fever,  measles, 
erysipelas,  typhoid  fever,  or  whooping-cough,  but  it  is  occasionally  pri- 
mary. It  is  sometimes  incited  by  the  inhalation  of  hot  steam,  the  fumes 
of  ammonia,  arsenic,  corrosive  sublimate,  or  other  irritating  substances. 

Morbid  Anatomy. — A  membrane  is  formed  which  is  identical  with 
that  of  diphtheria,  except  that  the  specific  bacillus  is  absent.  The  ex- 
udate is  most  frequently  found  in  the  larynx,  but  it  is  sometimes  con- 
fined to  the  tonsil,  or  it  may  affect  all  the  surfaces  usually  involved 
in  diphtheria.  The  membrane  is,  however,  more  loosely  attached  to  the 
mucous  membrane.  In  some  cases,  too,  just  as  in  diphtheria,  membrane- 
formation  is  wanting,  and  there  is  only  an  intensely  hyperemic  surface; 
and  in  other  cases,  again,  there  is  a  soft,  pultaceous  formation.  General 
streptococcous  infection  of  a  severe  type  sometimes  follows  the  local 
phenomena. 

The  symptoms  are  those  of  diphtheria,  but  they  are  generally  less 
severe  in  character.  Severe  attacks  are  occasionally  met  with,  however, 
and  death  has  repeatedly  occurred  in  cases  regarded  as  of  this  char- 
acter. The  affection  usually  lasts  about  a  week.  Albuminuria  is  sel- 
dom present,   and  other  complications  are  infrequent. 

The  treatment  is  that  of  diphtheria  affecting  the  same  region,  but 
without  antitoxin.  In  laryngeal  cases  inhalations  of  steam  are  of  the 
greatest  value.  Intubation  may  become  necessary  in  severe  cases.  The 
antitoxin  of  diphtheria  is  entirely  without  beneficial  influence,  but  should 
be  employed  in  a  severe  case  if  there  is  the  possibility  of  an  error  in 
diagnosis. 

WHOOPING-COUGH. 

PERTUSSIS,  TUSSIS  CONVULSIVA. 

Definition. — ^An  acute  infection  characterized  by  paroxysms  of  a 
convulsive  cough  followed  by  a  long-drawn  sonorous  inspiration  or 
whoop. 

Etiology. — The  disease  is  usually  conveyed  by  contagion.  It  may  be 
contracted  by  brief  contact  with  a  patient.  It  is  seldom  conveyed  by 
a  third  person,  but  clothing  and  houses  apparently  become  infected. 
The  poison  is  much  less  virulent  than  that  of  measles  or  scarlet  fever. 
The  sputum  and  probably  the  breath  convey  the  contagion.  Bacteria 
have  been  found  in  the  sputum  by  different  investigators.  Koplik  found 
a  short,  slender,  facultative,  anaerobic,  motile  bacillus,  probably  first 
described  by  Afanassieff,  in  13  of  16  cases,  and  Czaplewski  and  Hensel 
found  one  which  they  regarded  as  the  same  in  all  of  44  cases  examined. 
Absolute  immunity  is  usually  conveyed  by  an  attack;  natural  immunity 
is  rare.  Sporadic  cases  occur  at  all  seasons,  but  epidemics  are  more 
frequent  in  winter  and  spring.  They  frequently  precede  an  outbreak 
of  measles,  less  frequently  that  of  scarlatina.     Epidemics  last  two  or 


WHOOPING-COUGH  1 43 

three  months.  About  50  per  cent  of  the  cases  occur  during  the  first 
two  years  of  Hfe.  It  sometimes  attacks  infants  of  only  a  few  weeks, 
or  adults  up  to  advanced  age.  Girls  are  slightly  more  susceptible  than 
boys;  and  weak  children,  particularly  those  affected  with  catarrh,  more 
readily  contract  the  disease. 

Morbid  Anaiomy.—Tht  morbid  changes  are  rather  those  of  the  com- 
plications, of  which  pulmonary  collapse  and  bronchopneumonia  are 
the  most  frequently  found  in  fatal  cases.  Enlargement  of  the  tracheal 
and  bronchial  glands  is  constant. 

Symptoms. — The  course  of  the  disease  is  generally  divided  into  a 
catarrhal  and  a  paroxysmal  stage.  The  incubation  varies  from  a  few 
days  to  two  weeks.  The  catarrhal  stage  lasts  from  one  to  two  weeks 
and  is  characterized  by  slight  indisposition,  fever  at  night,  and  evi- 
dences of  laryngeal  or  bronchial  catarrh,  as  in  an  ordinary  cold.  The 
cough  is  usually  hoarse  and  becomes  peculiarly  sonorous,  and  finally 
paroxysmal.    The  face  becomes  swollen  and  the  lower  eyelids  puffy. 

The  paroxysmal  stage  begins  with  the  first  appearance  of  the  whoop. 
The  cough  becomes  distinctly  spasmodic.  It  is  of  a  rapid  staccato 
character  and  ceases  only  after  the  air  in  the  lungs  has  been  exhausted; 
and  it  is  followed  by  a  long  audible  inspiration,  the  air  being  drawn 
through  the  glottis  while  the  vocal  cords  are  approximated.  Several 
paroxysms  frequently  occur  in  succession  until  a  mass  of  tenacious 
mucus  is  expelled.  From  four  or  five  to  eighty  spells  occur  in  a  day; 
they  are  often  more  frequent  at  night.  They  are  brought  on  by  any 
slight  irritation  of  the  throat,  as  by  the  inhalation  of  dust  or  cold  air; 
and  the  child  soon  learns  to  refrain  from  laughing  or  talking,  even  from 
eating,  particularly  when  it  feels  the  aura-like  inclination  to  cough 
which  generally  precedes  the  attack.  As  the  spell  comes  on,  the  child 
generally  runs  to  its  mother  or  seizes  any  near  object  for  support.  Dur- 
ing a  severe  paroxysm  the  face  becomes  cyanotic,  the  thorax  is  con- 
tracted, the  eyeballs  protrude,  the  conjunctivse  become  injected,  often 
remaining  blood-shot,  and  hemorrhages  frequently  occur  from  the  mouth 
and  nose.  Hemoptysis  has  been  observed.  Convulsions  may  occur  in 
nervous  children.  Vomiting  very  generally  follows  a  paroxysm,  par- 
ticularly just  after  a  meal.  The  sphincters  sometimes  give  way.  A 
small  ulcer  generally  forms  under  the  tongue  during  the  disease. 

Examination  of  the  chest  during  an  attack  reveals  dullness  from  de- 
ficiency of  air  in  the  lungs;  during  the  intervals,  the  signs  are  those 
of  emphysema  and  bronchitis,  mucous  rales  and  absence  of  the  vesicu- 
lar murmur.  The  paroxysms  begin  to  diminish  in  frequency  and  severity 
in  three  or  four  weeks,  but  the  cough  continues  to  be  spasmodic  in  char- 
acter until  the  last.  The  contraction  of  a  cold  renews  the  peculiar 
cough  for  months  after  recovery. 

Comp/icaf/'ons  and  Seque/ce. — The  repeated  vomiting  and  subsequent 
inanition  induce  anemia.  Hemiplegia  has  been  induced  by  a  severe 
paroxysm,  and  sudden  death  has  occurred  from  subdural  hemorrhage. 
The  pulmonary  complications  are  the  most  frequent  and  most  important.' 
The  bronchitis,  enlargement  of  the  bronchial  glands,  and  emphysema 
may  persist.  Bronchopneumonia  sometimes  proves  a  fatal  complication,; 
or  tuberculosis  may  be  engrafted  upon  it.  Pleurisy  is  frequent,  l6bar' 
pneumonia  infrequent.    Pericarditis  and  lesions  of  the  valves  have  been 


144  PRACTICE  OF  MEDICINE 

attributed  to  the  great  strain  thrown  upon  the  heart  during  the  par- 
oxysms. Hernia  has  been  produced  by  the  violent  coughing.  Nephritis 
sometimes  occurs.  Anders  found  it  in  20  per  cent  of  cases,  but  Blumen- 
thal  found  only  increase  of  the  uric  acid,  with  high  specific  gravity. 
Leucocytosis  develops  early. 

Diagnosis. — The  whoop  is  pathognomonic,  but  in  young  infants  it  is 
often  absent.  A  dry  cough  with  an  occasional  short  whoop  sometimes 
occurs  in  other  catarrhal  affections  of  the  nose  and  throat. 

Prognosis. — The  frequency  and  severity  of  the  complications  always 
warrant  the  giving  of  a  guarded  prognosis.  The  bronchopneumonia 
is  almost  always  fatal.  The  younger  the  child,  the  greater  is  the  danger. 
The  mortality  is  very  high  among  the  children  of  the  poor,  probably 
owing  to  neglect.  Cases  among  all  classes  of  people  are  too  often  al- 
lowed to  run  their  course  without  treatment,  owing  to  the  popular 
fallacy  that  nothing  can  be  done  for  the  disease. 

Treatment. — Isolation  should  always  be  insisted  upon,  and  in  severe 
cases  the  patient  should  be  confined  to  bed  in  a  well-ventilated  room. 
Milder  cases,  in  warm  weather,  will  do  better  in  the  open  air.  The  diet 
should  be  light,  easily  digested,  consisting  largely  of  milk,  and  it  would 
best  be  given  in  small  quantities  at  short  intervals  on  account  of  the 
vomiting.  Removal  of  the  patient  from  the  city  to  the  country  is  im- 
mediately beneficial' in  most  cases. 

Local  Treatment. — Various  methods  of  local  treatment  have  been 
recommended.  These  are  applied  by  insufflation,  with  a  brush,  in  the 
form  of  spray,  or  by  inhalation.  Quinin  with  bicarbonate  of  soda  and 
powdered  gum  acacia,  or  a  mixture  of  quinin  and  resorcin,  has  been 
extensively  employed  by  insufflation  three  times  a  day.  Boric  acid, 
benzoin,  salicylic  acid,  iodoform,  and  other  powders  have  also  been  used. 
For  application  with  the  brush  or  swab,  a  2  per  cent  solution  of  re- 
sorcin or  carbolic  acid  has  been  recommended.  In  the  form  of  spray 
the  same  solutions  may  be  used,  and  equal  parts  of  h3^drogen  peroxid 
and  glycerin  are  highly  recommended.  For  inhalation,  the  vapor  of 
creosot,  naphthalin,  or  bromoform  and  ozone  has  been  recommended. 

Internal  Medication.-— Qviinin  and  belladonna  are  most  relied  upon. 
The  former  is  given  in  doses  of  i  to  2  grains  for  each  year  of  age, 
up  to  5,  three  times  daily,  and  the  belladonna  should  be  pushed  until  the 
face  flushes  after  each  dose.  They  may  be  given  together.  Bromoform 
in  I  to  5  minim  doses  has  been  highly  recommended,  but  should  be 
used  with  caution,  commencing  with  the  minimum  dose,  owing  to  its 
tendency  to  depress  the  heart. 

MUMPS. 
EPIDEMIC  PAROTITIS. 

Definition. — An  acute  infectious  disease  whose  chief  symptom  is  in- 
flammation of  the  parotid  gland. 

Etiology. — The  specific  cause  of  infection  is  not  known.  The  disease 
prevails  sporadically,  endemically,  and  sometimes  epidemically.  It  is 
highly  infectious  to  persons  coming  into  close  contact  with  those  aff'ected, 
and  the  contagium  may  be  carried  on  clothing.      It  frequently  attacks 


MUMPS  145 

more  than  90  per  cent  of  the  inmates  of  schools  and  barracks.  It  is 
most  prevalent  during  springtime  and  autumn.  Childhood  and  youth 
are  the  ages  of  greatest  susceptibility.  Infants  under  2  years  and 
adults  over  25  are  seldom  attacked.  Boys  are  more  frequently  affected 
than  girls.  One  attack,  including  possible  relapse,  generally  produces 
permanent  immunity. 

Morbid  Anaiomy.—A.  serous  exudation  into  the  glandular  and  peri- 
glandular tissues  of  the  parotid,  and  catarrhal  inflammation  of  the 
ducts,  constitute  the  usual  lesions  of  the  disease.  Suppuration  rarely 
occurs.  The  affection  is  limited  to  one  gland  in  some  instances.  The 
submaxillary  glands  may  be  affected,  alone  or  in  conjunction  with  the 
parotids.  In  boys  the  disease  is  not  infrequently  accompanied  by  in- 
flammation of  the  testes,  and  in  girls  by  inflammation  of  the  ovaries, 
vulva,  or  mammary  glands. 

Symptoms. — The  incubation  is  about  14  days,  without  symptoms. 
The  invasion  is  usually  announced  by  a  slight  elevation  of  temperature, 
seldom  beyond  101°  F.  (38.3°  C).  Nausea, vomiting,  headache,  and  rest- 
lessness may  be  present.  In  about  24  hours  after  the  onset,  slight  pain 
and  a  sense  of  fullness  in  the  region  of  the  parotid  gland  are  experienced. 
Swelling  is  soon  noticeable  and  by  the  third  day  forms  a  prominent 
protrusion  which  interferes  with  speech  and  deglutition  by  restricting 
the  opening  of  the  mouth.  Slight  deafness,  tinnitus,  earache,  pharyn- 
gitis, and  epistaxis  occasionally  add  to  the  discomfort.  After  a  day  or 
two  the  other  parotid  gland  usually  becomes  affected ;  it  is  seldom  that 
both  are  affected  in  the  beginning.  When  the  submaxillary  glands  alone 
are  involved,  the  swelling  is  confined  to  the  region  beneath  the  chin, 
but  may  extend  far  down  the  neck.  The  secretion  of  saliva  may  be 
either  increased  or  diminished.  The  more  severe  symptoms  generally 
abate  in  two  or  three  days,  and  the  swelling  slowly  subsides  after  a  week 
or  ten  days,  but  one  or  more  relapses  not  infrequently  occur.  In  the 
most  severe  cases  the  temperature  runs  high,  103°  or  104°  F.  (39.5° — 
40°  C),  and  nervous  symptoms  develop,  notably  delirium  or  stupor, 
occasionally  mania;  rarely,  the  patient  passes  into  a  typhoid  state. 

Orchitis  is  not  usually  seen  before  puberty.  It  may  occur  during 
the  height  of  the  disease,  seldom  earlier,  but  more  frequently  develops 
during  convalescence  and  is  accompanied  by  a  renewal  of  the  former 
constitutional  disturbances.  It  is  generally  unilateral,  but  it  may  in- 
volve both  testes  simultaneously  or  in  succession,  and  sometimes  lasts 
longer  than  the  original  parotitis.  Effusion  of  serum  into  the  tunica 
vaginalis,  edema  of  the  scrotum,  and  slight  urethral  discharge  often  ac- 
company the  condition.  The  epididymis  is  not  usually  involved.  Atro- 
phy of  one  or  both  glands  may  result.  Vulvovaginitis  sometimes  occurs 
in  girls;  ovaritis  is  rare.  The  mammary  glands  are  occasionally  in- 
volved in  boys,  though  not  so  frequently  as  in  girls. 

The  complications  and  sequeloB  are  few.  The  most  important  are 
those  on  the  part  of  the  nervous  system — meningitis,  peripheral  neuritis, 
and  paralyses  (hemiplegia  and  facial  paralysis),  or  edema  of  the  brain 
from  compression  of  the  jugular  vein.  Acute  mania  and  insanity  have 
followed  the  disease.  Stomatitis,  laryngitis,  and  otitis  media  are  oc- 
casionally encountered,  and  deafness  and  atrophy  of  the  optic  nerve  have 
been  attributed  to  the  disease. 


146  PRACTICE  OF  MEDICINE 

Diagnosis. — The  peculiar  character  of  the  swelHng,  free  from  redness  of 
the  skin  or  special  tenderness,  and  passing  around  the  lobule  of  the  ear, 
with  the  more  or  less  marked  constitutional  disturbance,  serves,  as  a 
rule,  to  distinguish  parotitis  from  other  inflammatory  affections  of  this 
region.    Idiopathic  parotitis  is  rare  in  childhood. 

Treatment. — The  patient  should  be  isolated  and  confined  to  bed  during 
the  acute  stage.  Hot  applications,  preferably  a  wad  of  absorbent  cot- 
ton wrung  out  of  hot  water  and  covered  with  oil  silk,  soothe  the 
pain  and  probably  reduce  the  inflammation.  Cold  applications  are 
preferred  by  some  patients.  Medicine  is  seldom  required  except  for  the 
relief  of  nervous  manifestations.  Two  to  5  grain  (0.15 — 0.30)  doses  of 
phenacetin,  according  to  age,  relieve  the  headache  and  reduce  the  fever. 
The  bowels  should  be  kept  open  with  saline  laxatives.  If  orchitis  develop, 
the  testicles  should  be  elevated  and  treated  with  hot  or  cold  applications. 
Thompson  recommends  the  application  of  equal  parts  of  guaiacol  and 
glycerin  or  30  per  cent  ichthyol  in  lanolin. 

SEPTICEMIA. 

SEPSIS,  BACTEREMIA,  BLOOD-POISONING. 

Definition. — A  general  disease,  caused  by  the  entrance  of  pyogenic  mi- 
cro-organisms or  their  toxins  into  the  blood,  and  characterized  by 
chills,  irregular  fever,  sweating,  and  great  prostration. 

Etiology. — The  phenomena  of  septicemia  are  commonly  preceded  by 
suppuration,  but  the  location  of  the  suppuration  is  not  always  recognized 
before  the  development  of  the  septic  condition.  The  pyogenic  micro- 
organisms become  localized  at  one  or  more  points  within  the  body  or  on 
an  abraded  cutaneous  or  mucous  surface,  and  there  set  up  a  suppurative 
or  putrefactive  process.  From  this  the  bacteria  or  their  toxins,  or  both 
bacteria  and  toxins,  gain  entrance  to  the  general  system  through  the 
blood  or  lymph  circulation  or  through  both  these  channels.  It  is  an 
essential  feature  of  septicemia  that  no  secondary  foci  of  suppuration 
are  developed.  In  this  regard  it  is  distinguished  from  pyemia.  Any 
disease  or  condition  attended  by  suppuration  may  become  a  cause  of 
septicemia.  Among  these  are  abscesses  of  the  breast,  lymph-glands, 
liver  or  other  organs,  empyema,  suppurative  peritonitis,  chronic  otitis, 
malignant  endocarditis,  and  pyelitis.  Sepsis  is  a  common  termination 
of  chronic  tuberculosis. 

Bacteriology. — The  bacteria  most  frequently  causing  the  disease  are  : 
(i)  The  Streptococcus  pyogenes,  (2)  Staphylococcus  pyogenes  aureus, 
(3)  Gonococcus,  (4)  Micrococcus  lanceolatus,  (5)  Bacillus  pyocya- 
neus,  (6)  Bacillus  proteus,  (7)  Bacillus  influenzte,  (8)  Bacillus  typhosus, 
(9)  Bacillus  coli  communis,  and  (10)  the  Bacillus  aerogenes  capsulatus. 
Of  these  the  most  important  are  the  first  and  second.  Klebs  and  Koch 
attribute  the  disease  to  a  specific  microbe  which  is  smaller  than  the 
pus-forming  organisms. 

The  term  septicemia  is  sometimes  applied  to  conditions  in  which  the 
blood  becomes  highly  charged  with  the  toxins  of  other  bacteria,  but 
toxemia  is  a  better  designation  for  these.  Conditions  closely  resembling 
septicemia  have  been  induce  by  Bergmann,  Angerer,  and  others  through 
the  injecting  into  the  blood  of  pepsin,  pancreatin,  and  trypsin. 


SEPTICEMIA  147 

Infection  may  occur  through  an  incised  wound,  as  in  surgical  septi- 
cemia, or  through  accidental  wounds  or  abrasions.  In  puerperal  sepsis 
it  is  taken  up  from  the  uterine  canal.  The  serous  membranes,  especially 
the  pleura  and  peritoneum,  or  the  mucous  membranes  of  the  respiratory 
or  alimentary  canal,  not  infrequently  admit  the  poison,  and  suppuration 
of  bone  is  often  the  source  of  infection.  Suppurating  lymph-glands  in 
any  part  of  the  body  may  act  as  hidden  foci  of  infection  in  the  so- 
called  cryptogenic  form  of  the  disease. 

Motbid  Anatomy. — In  sapremia  and  fermentation  fever  there  are  usually 
no  lesions.  In  true  septicemia  death  not  infrequently  occurs  before 
recognizable  lesions  have  been  produced.  In  cases  that  have  run  a  less 
rapid  course  the  most  striking  feature  is  a  condition  in  which  the 
body  undergoes  rapid  putrefaction.  The  blood  is  black  and  tar-like 
and  the  muscles  are  dark.  Hyperemia  and  ecchymoses  are  often 
found  in  the  pia,  pleura,  pericardium,  and  peritoneum,  and  punctiform 
hemorrhages  may  be  found  in  the  skin.  The  spleen  and  lymph-glands 
are  usually  enlarged,  and  the  spleen  may  be  soft.  The  liver  and  kidneys 
show  cloudy  swelling  and  sometimes  other  degenerations.  Bacteria  may 
be  found  in  great  numbers  in  the  various  tissues,  especially  in  inflam- 
matory foci,  or  exudations,  and  in  the  renal  glomeruli.  It  has  been  sug-^ 
gested  that  the  presence  of  numerous  bacteria  in  the  blood  and  tissues 
after  death  may  be  in  part  due  to  an  agonal  or  post-mortem  invasion 
or  to  the  rapid  growth  after  death  of  a  few  organisms  present  during 
life. 

Varieties  of  Septicemia.  —  i.  True  or  Progressive  Septicemia. — Senn 
restricts  the  use  of  this  term  to  cases  which  are  caused  by  the  en- 
trance into  the  circulation  of  microbes  from  some  local  septic  focus. 
It  is  caused  not  only  by  poisons  which  are  produced  at  the  primary 
seat  of  infection,  but  also  by  those  produced  in  the  blood  by  the  bac- 
teria which  it  contains.  2.  Sapremia  is  the  septic  intoxication  caused 
by  the  entrance  into  the  blood  of  toxins  or  ptomains  previously  formed 
by  putrefactive  bacteria  in  dead  tissues.  It  is  not  accompanied  by  the 
entrance  of  bacteria,  and  usually  subsides  as  soon  as  the  primary  cause 
has  been  removed.  3.  Intesti?ial  or  Ptomain  Poisoning. — This  form  was 
first  described  by  Vaughan  as  due  to  the  absorption  of  tyrotoxicon,  a 
poisonous  chemical  substance  often  found  in  cheese.  The  same  investi- 
gator and  others  have  since  added  to  the  list  a  large  number  of  other 
poisonous  ptomains.  Strictly  classified,  poisoning  by  these  substances 
is  a  form  of  sapremia.  The  term  is  sometimes  employed,  however,  to 
designate  conditions  in  which  the  bacteria  have  found  their  way  into 
the  circulation  through  the  intestinal  canal,  particularly  with  reference 
to  the  bacillus  coli  communis. 

Fermentation  Fever.— Closely  allied  to  these  conditions  is  that  known 
as  fermentation,  aseptic,  or  resorption  fever.  It  is  a  general  febrile 
disturbance  caused  by  the  absorption  of  the  products  of  aseptic  tissue 
necrosis.  It  appears  as  a  temporary  condition  soon  after  injuries  and 
operations  in  which  bacterial  invasion  has  not  occurred,  but  more  par- 
ticularly when  there  has  been  extravasation  of  blood.  It  is  supposed, 
in  some  cases  at  least,  to  be  due  to  the  entrance  into  the  circulation  of 
fibrin  ferment.  It  resembles  sepsis  only  in  the  febrile  character  of  its 
symptoms. 


148  PRACTICE  OF  MEDICINE 

Symptoms. — (i)  In  septice7nia,  the  period  of  incubation  lasts  from  a 
few  hours  to  several  days.  The  onset  is  usually  gradual  and  is  not  an- 
nounced by  a  chill.  There  is  generally  a  distinct  rise  of  temperature 
varying  greatly  in  degree  in  different  cases.  Headache,  nausea,  vomit- 
ing, prostration,  and  mental  dullness  are  generally  present.  Diarrhea 
may  be  an  early  symptom,  but  constipation  is  more  common  in  the 
beginning.  The  fever  may  reach  only  ioo°  F.  (38.0°  C.)  in  mild  cases, 
but  may  exceed  110°  F.  (43.5°  C.)  in  the  worst.  It  is  usually  a  con- 
tinuous fever,  but  the  daily  fluctuations  may  amount  to  3°  or  4°F. 
The  pulse  is  rapid,  often  130  or  over,  usually  small  and  tense;  sometimes 
it  is  soft  and  feeble.  Leucocytosis  is  usually  present.  Cabot  remarks 
in  this  connection  that  leucocytosis  indicates  a  struggle  between  the 
system  and  the  infection,  and  that  it  may  be  absent  in  the  mildest 
and  severest  cases.  The  respiration  is  rapid  and  superficial.  Cyanosis 
is  sometimes  present.  The  skin,  at  first  hot  and  dry,  becomes  bathed 
with  a  profuse  perspiration.  In  mild  cases  all  symptoms  frequently  sub- 
side within  from  24  to  72  hours;  and  in  the  severe,  or  fulminant,  cases 
death-  may  occur  within  the  same  limit  of  time.  Other  cases  run  a 
variable  course  of  from  four  or  five  days  to  as  many  weeks,  and  chronic 
cases  last  for  months.  The  symptoms  in^  the  chronic  form  are  often 
severe,  but  run  a  remittent  or  intermittent  course.  The  exacerbations 
are  frequently  accompanied  by  a  rigor,  and  chilly  sensations  or  distinct 
chills  often  occur  independently  of  remissions  or  exacerbations.  Diarrhea 
may  develop  and  the  patient  become  anemic  and  emaciated.  Erythema, 
petechise,  punctate  hemorrhages  or  ecchymoses,  and  other  cutaneous 
eruptions  not  infrequently  develop. 

(2)  The  symptoms  of  sapremia  differ  much  in  difterent  cases.  At 
times  they  are  quite  like  those  of  septicemia,  but  are  usually  of  shorter 
duration.  Severe  cases  are  initiated  by  a  chill  and  continuous  fever, 
reaching  from  102°  to  104°  F.  (39°— 40°  C),  with  slight  morning  re- 
missions. A  soft,  full,  compressible  pulse  is  quite  characteristic.  Anorexia, 
vomiting,  and  diarrhea  are  frequently  present,  particularly  in  the  intes- 
tinal form.  The  tongue  is  furred,  becomes  dr)^,  assuming  a  '"  dried-beef" 
appearance  in  severe  cases.  The  urine  is  scant,  rich  in  urates,  and  in- 
creased in  toxicity.  All  symptoms  quickly  subside  upon  removal  of  the 
cause. 

(3)  The  s3^mptoms  oS.  fermentation  fevcj-;  The  temperature  usually 
rises  rapidly  without  a  chill,  reaching  a  maximum  of  from  100°  to  104° 
F.  (38° — 40°  C).  It  then  remains  almost  stationa.ry  for  from  one  to 
three  days  and  drops  suddenly  to  normal.  The  pulse  undergoes  a  cor- 
responding acceleration.  There  is  usually  little  or  no  disturbance  of 
the  nervous  system,  the  sensorium  remaining  clear  or  even  appearing 
stimulated  to  greater  activity. 

Diagnosis. — This  depends,  in  many  cases,  upon  the  recognition  of  the 
source  of  infection.  The  frequent  chills,  irregular  temperature,  and  sweat- 
ing, with  rapid  production  of  anemia  and  emaciation,  should  always 
arouse  suspicion  of  sepsis  in  an  obscure  case.  Secondary  abscesses  be- 
long to  p3''emia,  not  to  septicemia.  The  appearance  of  leucocytosis  is 
often  a  valuable  feature  in  diagnosis. 

Typhoid  Fever. — This  disease  is  usually  recognized  by  the  more  grad- 
ual elevation  and  more  uniform  course  of  the  fever,  the  absence  of  chills 


SEPTICEMIA  149 

during  its  course,  the  rose-spots  and  the  absence  of  leucocytosis.  But 
the  disease  is  not  infrequently  compHcated  by  septicemia  or  sapremia, 
causing  a  modification  of  its  symptoms. 

Malaria,  especially  of  the  estivo-autumnal  or  remittent  type,  resembles 
septicemia,  but  the  course  is  generally  more  uniform ;  the  greater  splenic 
enlargement,  the  absence  of  suppurative  foci,  and,  above  all,  the  presence 
of  the  Plasmodium  in  the  blood  establish  the  diagnosis. 

Chronic  Tuberculosis. — In  this  disease  many  of  the  symptoms  are 
due  to  sepsis,  hence  the  differentiation  must  often  depend  upon  the  dis- 
covery of  pulmonary  or  other  lesions  and  the  isolation  of  the  tubercle 
bacillus.  In  acute  miliary  tuberculosis,  the  cough,  rapid  respiration, 
and  the  discovery  of  the  bacillus  in  most  cases  serve  to  differentiate 
the  affection. 

Prognosis. — In  mild  cases  of  sepsis,  in  most  cases  of  sapremia,  and 
in  all  cases  of  fermentation  fever  the  prognosis  is  good.  In  acute  sep- 
ticemia it  is  always  grave.  In  all  septic  cases,  however,  as  much  depends 
upon  the  physical  condition  of  the  patient  as  upon  the  virulence  of  the 
infection.  There  is  much  difference  in  individual  power  of  resistance. 
Rapidly  fatal  cases  sometimes  follow  the  most  trivial  surgical,  dissection, 
or  post-mortem  wounds;  while  cases  arising  from  the  most  extensive 
suppuration  often  recover  after  months  of  severe  illness.  The  early 
removal  of  the  cause,  when  this  is  possible,  has  a  decidedly  favorable 
influence  on  the  prognosis. 

Prophylaxis  consists  in  the  strict  observance  of  antiseptic  precau- 
tions, the  removal  of  extravasated  blood,  and  the  prompt  evacuation 
of  pus  cavities.  Attention  to  the  condition  of  the  hands,  especially  with 
reference  to  slight  abrasions,  before  undertaking  surgical  or  post-mortem 
work,  is  of  the  utmost  importance.  When  an  injury  is  received  during 
an  operation,  bleeding  should  be  encouraged  or  increased  by  sucking, 
and  the  wound  should  be  immediately  cauterized. 

Treatment — The  cause  should  be  promptly  removed.  In  fermentation 
fever,  the  establishment  of  drainage  or  antiseptic  irrigation  is  usually 
all  that  is  required.  In  sapremia  of  intestinal  origin,  prompt  purgation 
by  calomel,  castor  oil,  or  a  saline  cathartic  is  often  sufficient.  Intestinal 
antiseptics,  salol,  or  /S-naphthol  in  5-grain  doses  may  be  employed. 
In  septicemia  the  treatment  is  largely  symptomatic.  The  temperature 
may  be  reduced  by  frequent  sponging  or  cold  bathing.  Antipyretics 
should  be  avoided  on  account  of  their  depressing  effect.  The  strength  of 
patient  must  be  supported  by  a  nutritious,  easily  digested  diet,  con- 
sisting of  milk,  broths,  eggs,  egg-nog,  and  gruels.  Codliver  oil  and  malt 
preparations  are  beneficial  in  chronic  cases.  The  heart's  action  should 
be  supported  by  strychnin,  gr.  1-30  (0.002),  and  alcohol.  The  action 
of  the  kidneys  should  be  favored  by  the  administration  of  large  quanti- 
ties of  water  and  potassium  acetate,  gr.  x  (0.65),  or  liquor  ammoniac 
acetatis,  3  ss  (2.0).  Quinin  in  large  doses,  gr.  x  to  xx  (0.65 — 1.3), 
proves  of  great  benefit  in  some  cases,  but  is  useless  in  others.  Diarrhea, 
when  excessive,  must  be  controlled  by  opiates.  Marmorek's  antistrepto- 
coccous  serum  may  be  injected,  but  it  is  not  always  of  benefit.  Inunctions 
of  unguentum  Credd,  a  preparation  of  metallic  silver,  have  been  recom- 
mended, but  are  often  disappointing.  About  3  i  (4.0)  daily  is  rubbed 
into  the  sides  of  the  thighs,  abdomen,  and  other  regions  in  succession 


I50  PRACTICE  OF  MEDICINE 

as  in  the  administration  of  mercurial  inunctions.  In  many  cases  sur- 
gical measures  must  be  resorted  to.  Wernitz  has  strongly  recommended 
slow,  protracted  irrigation  of  the  intestine  with  a  0.5  to  i  per  cent 
saline  solution  under  low  pressure.  The  intravenous  injection  of  formahn 
solution  (i  15000)  has  also  been  resorted  to,  with  success  in  a  few  cases. 
From  500  to  750  c.c.  of  the  solution  were  introduced  at  each  injection. 
The  measure  is  not  free  from  danger. 

PYEMIA. 

SEPTICOPYEMIA. 

Definition. — An  acute  febrile  disease  caused  by  the  entrance  of  pus- 
forming  micro-organisms  into  the  blood,  and  characterized  by  high  fever, 
frequent  chills,  and  sweating,  with  the  formation  of  metastatic  abscesses, 
phlebitis,  infarcts,  and  hemorrhages  in  various  parts  of  the  body.  It 
is  pathologically  identical  with  septicemia,  except  in  the  production  of 
secondary  suppurative  processes. 

Etiology. — Streptococci  and  staphylococci  are  the  most  frequent 
causes  of  the  infection,  but  the  other  bacteria  named  under  the  Etiology 
of  Septicemia  may  be  operative  in  its  production,  and  the  same  suppura- 
tive conditions  may  be  the  sources  of  infection.  The  avenue  of  entrance 
is  usually  through  the  wall  of  a  vein  which  is  in  a  state  of  inflammation 
and  degeneration.  Entrance  through  the  lymph-vessels  is  possible,  but 
the  germs  must  reach  the  general  circulation  before  pyemia  can  develop. 

Pat/io/ogy.— There  is  first  a  point  of  suppuration  adjacent  to  or 
involving  a  vein,  rarely  an  artery.  A  suppurative  phlebitis  (or  arter- 
itis) is  thus  induced.  Thrombi  are  formed,  and  the  pyogenic  bacteria 
find  their  way  into  the  clot,  soften  and  disintegrate  it  into  numerous 
fragments  which  are  carried  off  in  the  circulation  as  emboli.  When 
a  vein  is  involved,  the  septic  emboli  are  generally  arrested  in  the  lungs, 
and  the  abscesses  may  be  confined  to  them.  If,  however,  a  radicle  of 
the  portal  vein  is  involved,  the  emboli  are  distributed  to  the  Uver. 
From  a  malignant  endocarditis  the  pus  is  distributed  to  all  parts  of 
the  body. 

The  lesions  found  after  death  depend  to  a  great  extent  upon  the 
duration  of  the  disease.  If  death  have  occurred  early,  the  original 
phlebitis  and  the  suppurative  infarctions  may  be  found.  At  a  little  later 
period,  numerous  miliary  abscesses  are  often  discovered.  In  more  pro- 
tracted cases  there  may  be  abscesses  from  one  to  four  inches  in  diameter, 
especially  in  the  liver,  lungs,  spleen,  or  kidneys,  sometimes  in  the  brain, 
joints,  or  serous  cavities.  Subcutaneous  abscesses  may  occur,  especially 
in  the  vicinity  of  the  joints.  The  heart  muscles  are  usually  soft,  the 
spleen  is  enlarged,  soft,  and  dark,  and  ecchymoses  are  often  revealed 
upon  the  surface  of  the  pleura  or  pericardium,  or  hemorrhages  in  the 
subcutaneous  tissue. 

Symptoms. — Wound  septicemia  is  always  a  sequel  to  suppuration, 
hence  it  seldom  develops  earlier  than  the  seventh  to  the  fourteenth 
day  after  the  receipt  of  the  injury.  The  infection  ma)^  be  preceded  by 
changes  in  the  wound.  The  granulations  become  pale,  and  the  pus  thin 
and  ichorous  or  saneous  and  scant.     The  edges  of  the  wound  become 


ERYSIPELAS  151 

puffy  and  edematous.  A  thrombosis  in  one  or  more  veins  leading  from 
the  focus  of  suppuration  may  be  recognizable  on  close  examination. 
Mild  symptoms  of  intoxication  may  precede  those  of  the  infection,  nota- 
bly a  slight  rise  of  temperature  and  mental  depression.  The  pyemic 
invasion  is  announced  by  a  severe  chill,  and  the  temperature  rises  to 
104°,  105°  F.  (40° — 40.5°  C.)  or  higher  before  the  shivering  ceases. 
Headache,  vomiting,  and  extreme  prostration  are  usual  accompaniments. 

The  pulse  becomes  rapid,  often  140  to  160,  and  feeble.  Chills  occur 
at  short  intervals,  daily  or  every  other  day,  or  there  may  be  two  or 
three  chills  a  day.  They  often  increase  in  frequency  and  severity  as  the 
disease  progresses.  The  temperature  range  in  acute  cases  is  irregular, 
intermittent  or  remittent,  with  fluctuations  amounting  to  several  de^ 
grees  in  some  cases,  but  seldom  declining  to  the  normal.  In  severe 
cases  intermissions  occur  in  which  the  temperature  becomes  normal  or 
subnormal.  Profuse  sweating,  anemia,  and  rapid  emaciation  are  charac- 
teristic of  the  disease.  The  tongue  becomes  dry,  the  breath  has  a  sweet- 
ish odor,  and  sordes  often  form  on  the  teeth.  The  skin  becomes  pale 
or  of  a  dusky  color,  the  features  pinched,  the  expression  anxious. 
Slight  jaundice  is  occasionally  seen.  Nervous  symptoms  are  usually 
absent  until  late  in  the  disease.  Delirium  develops  in  severe  cases  and 
deepens  into  coma  as  the  fatal  issue  approaches.  If,  however,  metasta- 
tic meningitis  develops,  it  is  promptly  announced  by  strabismus,  ptosis, 
deafness,  and  hemiplegia.  Other  symptoms,  particularly  pain,  tenderness, 
and  swelling,  occur  as  a  result  of  thrombosis,  infarction,  or  abscess 
formations  in  different  parts  of  the  body.  WTien  these  form  in  the  lungs, 
rapid  respiration,  cough,  and  dyspnea  are  produced,  sometimes  with 
purulent  or  bloody  expectoration.  Malignant  endocarditis  is  attended 
with  increased  pulse-rate  and  temperature,  dyspnea,  and  a  harsh  sys- 
tolic bruit.  Leucocytosis,  reduction  of  erythrocytes,  and  moderate 
poikilocytosis  are  the  usual  blood-changes.  Cutaneous  eruptions,  ery- 
thema, purpura,  or  pustules  may  occur,  and  hyperesthesia  is  commonly 
present.  The  urine  is  febrile  in  character,  often  contains  albumin,  casts, 
and  sometimes  pus  and  blood-corpuscles.  Albumose  has  been  found  in 
it.  Suppurative  inflammation  of  the  joints  is  not  uncommon  late  in 
the  disease,  sometimes  after  the  fever  has  subsided. 

Diagnosis. — Pyemia  may  be  distinguished  from  septicemia,  as  a  rule, 
by  the  extreme  fluctuation  of  the  temperature,  the  frequency  of  chills, 
and  yet  more  particularly  by  the  thromboses,  infarctions,  and  metas- 
tatic abscesses.  In  other  respects  the  symptoms  are  practically  the 
same.  The  features  thus  combined  serve  to  differentiate  pyemia  from 
almost  all  other  affections. 

Treatment. — This  is  in  all  respects  the  same  as  that  of  septicemia. 

ERYSIPELAS. 

Definition. — An  acute  febrile  disease  caused  by  the  streptococcus  of 
Fehleisen,  affecting  primarily  the  skin  or  a  mucous  membrane  and 
producing  general  symptoms  of  toxemia  resembling  those  of  sepsis. 

Etiology. — The  streptococcus  described  by  Fehleisen  is  regarded  as 
the  specific  cause.  Attempts  to  produce  the  disease  by  inoculating  with 
other    cocci    have    not    been    entirely  successful,   although  some  of  the 


152  PR.\CTICE  OF  MEDICINE 

features  of  erysipelas  have  been  produced.  The  poison  is  evidently  not 
extremely  virulent,  since  it  does  not  act  at  a  great  distance.  The  dis- 
ease is  contagious  and  inoculable,  however,  and  it  may  be  communicated 
by  a  third  person,  probably  also  by  fomites.  It  clings  tenaciously  to 
furniture  and  the  walls  of  houses,  especially  in  old,  poorly  ventilated 
hospitals  and  damp  cottages.  An  injury  or  break  in  the  continuity  of 
the  epithelial  surface  is  regarded  as  essential  for  the  admission  of  infec- 
tion, although  this  is  frequently  so  shght  as  to  escape  careful  search  for 
it.  The  disease  frequently  attacks  the  subjects  of  surgical  operations  or 
women  after  confinement.  It  may  follow  vaccination.  No  injury  is  too 
trifling  to  admit  the  infection.  Alcoholism,  Bright' s  disease,  inanition, 
debihty,  physical  exhaustion,  previous  illness,  bad  hygiene,  and  filthy 
habits  all  predispose  to  the  disease.  Certain  individuals  and  famihes 
are  particularly  susceptible.  Some  persons  are  attacked  regularly  at 
about  the  same  time  every  year,  particularly  if  they  continue  to  reside 
in  the  same  dwelling.  Of  individual  immunity  little  is  known.  One 
attack  does  not  confer  immunity. 

Age  is  probably  not  of  importance,  since  the  disease  occurs  in  all. 
It  is  less  frequent  toward  the  extremes  of  Hfe,  probably  on  account  of 
less  exposure.  For  the  same  reason,  no  doubt,  men  are  oftener  attacked 
than  women.  Springtime  is  the  period  of  its  greatest  prevalence.  The 
disease  is  endemic  in  most  places.  Epidemics  are  much  less  frequent 
since  the  introduction  of  antiseptic  methods  into  surgery  and  mid- 
wifery and  of  better  sanitation  into  hospitals  and  dwellings. 

Bacteriology.— T\iZ  streptococcus  is  known  also  by  the  names  Strep- 
tococcus erysipelatis  and  S.  pathogenis  longus.  It  is  peculiar  in  its 
forming  long,  slender  chains,  in  its  growth  on  different  media,  and  in  the 
fact  that  it  produces  this  disease  when  inoculated  into  man  or  susceptible 
animals.  It  is  probably  a  facultative  aerobe.  It  cannot  be  distinguished 
morphologically  from  the  ordinary  streptococci  of  suppuration. 

Morbid  Anatomy.— Tht  lesions  are  found  in  the  skin  or  mucous  mem- 
branes. The  local  process  is  one  of  hyperemia  which  rapidly  spreads 
from  the  point  of  original  entrance  for  a  variable  distance  in  one  or  more 
directions.  Fehleisen  described  three  zones  in  the  erysipelatous  area  : 
A  central  zone  in  which  the  process  may  be  receding,  a  middle  circle  in 
which  the  disease  is  still  advancing,  and  an  outer  in  which  it  is  only 
beginning.  Section  of  the  affected  area  reveals  an  infiltration  of  the 
skin  and  subcutaneous  tissue,  often  including  the  fat,  with  granular 
leucocytes  and  serum.  The  leucocytes  are  most  numerous  in  the  cap- 
illaries and  lymph-spaces  of  the  peripheral  zone;  they  are  often  particu- 
larly numerous  also  about  the  hair-follicles  and  sweat-glands.  The 
edema  is  most  pronounced  in  loose  cellular  tissue,  as  about  the  eyelids, 
prepuce,  etc.  A  proliferation  of  fixed  connective-tissue  cells  is  described 
by  some  pathologists.  Metchnikoff  beheves  that  the  inflammation  is 
arrested  in  the  outer  zone  by  an  accumulation  of  phagocytes. 

The  visceral  lesions  are  those  usually  accompanying  sepsis  and  fever, 
and  are  not,  therefore,  pecuhar  to  the  disease.  Abscesses  and  infarctions 
are  occasionally  found  in  the  lungs,  spleen,  and  kidneys.  Malignant 
endocarditis,  septic  pericarditis,  or  pleuritis  is  sometimes  found.  Men- 
ingitis and  edema  of  the  brain  are  not  infrequent,  and  pneumonia  is 
occasionally  developed.    Nephritis  is  not  common. 


ERYSIPELAS  153 

Symptoms. — The  incubation  varies  from  48  hours  to  seven  days. 
There  are  usually  no  symptoms,  but  malaise,  anorexia,  and  slight  fever 
may  be  present.  An  initial  chill  is  almost  invariably  the  mode  of  on- 
set. It  may  be  repeated,  and  is  generally  accompanied  by  headache, 
muscular  pains,  sometimes  by  vomiting.  The  severity  of  the  rigor  is 
generally  regarded  as  an  index  to  the  severity  of  the  disease.  The  tem- 
perature runs  up,  often  to  104°  F.  (40°  C.)  or  higher.  In  an  ordinary 
case  it  remains  high  with  but  slight  remissions  for  four  or  five  days,  then 
rapidly  subsides.  Headache  and  delirium  are  especially  liable  to  occur 
when  the  scalp  is  affected.  Nervous  manifestations  are  especially  fre- 
quent in  alcoholic  cases.  Albuminuria  is  usually  present.  In  severe 
cases  the  pulse  becomes  rapid  and  feeble,  delirium  deepens  into  coma, 
the  tongue  becomes  dry,  hyperpyrexia  develops,  and  death  may  occur 
within  a  few  hours  from  toxemia. 

The  local  manifestations  of  the  disease  are  to  be  seen  at  the  point 
of  original  infection.  This  is  often  at  the  junction  of  the  skin  with  a 
mucous  membrane,  at  the  inner  canthus,  or  on  any  part  of  the  face 
or  ear.  The  part  appears  intensely  red  and  swollen.  The  surface  tem- 
perature is  raised  from  1°  to  4°  F.  (0.5° — 2°  C).  Itching,  burning, 
and  tension  are  complained  of.  The  area  varies  in  form  and  is  often 
irregular,  but  is  readily  distinguishable  from  the  surrounding  skin  by 
its  color  and  elevation.  The  process  reaches  its  acme  in  three  days, 
then  begins  to  decline.  The  disease  may,  however,  be  prolonged  by  slow 
or  rapid  extension.  The  entire  face  is  often  involved  and  sometimes  the 
entire  body  (erysipelas  migrans).  The  skin  is  usually  smooth  and  glossy, 
but  vesicles  sometimes  form,  and,  by  coalescing,  produce  large  bullae 
resembling  blisters.  In  its  progress  the  disease  follows  the  lymph-chan- 
nels, as  is  shown  by  red,  edematous  lines  radiating  from  the  periphery 
of  the  inflamed  area.  The  neighboring  lymph-glands  become  enlarged 
and  occasionally  suppurate.  Abscesses  are  formed  also  in  some  cases 
by  an  invasion  of  the  deeper  tissues  by  the  streptococci.  The  disease 
sometimes  invades  the  mucous  membrane  of  the  mouth  and  pharynx; 
but  it  is  not  invariably  severe  in  this  location.  The  larynx  sometimes 
becomes  edematous  through  an  extension  of  the  inflammation  from  the 
skin  directly  through  the  intervening  tissues.  The  cutaneous  eruption 
is  followed  by  profuse  desquamation  in  most  cases. 

Complicaiions  and  sequelce  are  rare,  with  the  exception  of  those  of 
a  septic  character,  to  which  reference  has  been  made  under  the  patho- 
logical anatomy.  Acute  rheumatism  has  been  observed.  Pulmonary 
erysipelas  is  described  by  Strauss,  and  Ivanowski  saw  the  lesions  of 
erysipelas  in  the  large  intestine  as  an  extension  from  the  perineum. 
Peripheral  neuritis  has  been  observed  as  a  sequel. 

Diagnosis. — There  is  rarely  any  difficulty  in  recognizing  the  disease 
when  it  affects  the  skin.  When  the  oral  or  nasal  mucous  membrane  is  af- 
fected, the  intense  redness,  swelling,  burning  pain,  with  high  temperature 
and  enlargement  of  lymph-nodes,  should,  in  the  absence  of  other  specific 
cause,  excite  suspicion  of  this  disease.  Other  forms  of  adejiiiis  are  not 
accompanied  by  so  great  fever.  Erythema  is  not  accompanied  by  enlarge- 
ment of  the  glands,  does  not  show  the  three  zones  or  the  elevation  of 
erysipelas.  Glanders  at  the  beginning  is  accompanied  with  hard,  edema- 
tous induration,  but  the  edges  are  not  so  much  elevated. 


154  PRACTICE  OF  MEDICINE 

The  prognosis  is  favorable  except  in  infants,  puerperal  women,  and 
alcoholic  or  debilitated  subjects.  When  the  mucous  membrane  of  the 
respiratory  tract  is  involved  the  prospect  is  less  favorable.  The  general 
mortality,  according  to  Anders,  is  5.6  per  cent. 

Prophylaxis. — The  patient  should  be  strictly  isolated,  and  the  most 
rigid  methods  of  antisepsis  should  be  adopted,  as  in  other  acute  infec- 
tious diseases.  The  physician  while  attending  a  case  of  erysipelas  should 
not  undertake  an  obstetric  case  or  surgical  operation  of  any  kind. 

Treatment — Internal  medication  is  usually  unnecessary,  except  to 
meet  symptoms  as  they  arise.  The  diet  should  be  light  and  nutritious, 
and  stimulants  and  tonics  should  be  administered  in  adynamic  or  alco- 
holic cases.  The  tincture  of  iron  is  not  regarded  with  so  much  favor 
as  formerly,  but  is  useful  in  ordinary  doses  (15  drops  in  water  after 
meals)  during  convalescence.  The  bromids,  trional,  or  morphin  may  be 
required  to  induce  sleep. 

Zoca/  Treatment. — Many  remedies  have  been  recommended,  but  ichthyol 
is  probably  the  most  effective.  It  may  be  applied  in  aqueous  solution, 
in  oil,  or  in  an  ointment  in  the  strength  of  from  15  to  25  per  cent, 
■covering  the  entire  surface  and  a  surrounding  area.  A  mask  of  lint 
should  be  worn  over  the  affected  part  to  protect  it  from  the  air.  So- 
lutions of  corrosive  subhmate  (i  :iooo),  the  lead  and  opium  wash,  or 
ointments  containing  carbolic  acid  or  other  antiseptic  drugs,  but  par- 
ticularly salicylic  acid,  are  almost  as  effective.  With  a  view  to  preventing 
the  extension  of  the  disease,  collodion  may  be  applied  to  the  healthy 
skin  just  outside  of  the  infiltrated  area  so  as  to  completely  surround  it, 
•or  a  2  per  cent  solution  of  carbolic  acid  or  i  12500  solution  of  mer- 
curic chlorid  or  biniodid  may  be  injected  into  the  skin. 

ACUTE  RHEUMATISM. 

ACUTE  ARTICULAR  RHEUMATISM,  ACUTE  INFLAMMATORY  RHEUMATISM, 

RHEUMATIC  FEVER. 

The  term  rheumatism  has  unfortunately  been  applied  to  a  great  number  of  very  dif- 
ferent affections,  and  it  is  probable  that  some  of  the  conditions  now  thought  to  be  rheu- 
matic will  in  the  future  prove  to  be  etiologically  different.  The  word  rheumatism  has 
been  handed  down  from  the  time  of  the  ancient  Greek  writers,  when  the  disease  was  attrib- 
uted to  a  humor  Q>fv}ia)  flowing  through  the  system. 

Definition.— Axi  acute  infectious  disease  manifesting  high  fever,  inflam- 
mation of  the  joints,  profuse  sweating,  and  a  tendency  to  involvement 
of  the  endocardium  and  other  fibrous  structures. 

Etiology. — The  specific  cause  is  yet  unknown.  Bacteria  have  been 
found  in  the  joints  and  other  lesions,  but  their  etiological  relation  has 
not  been  proved.  It  has  been  suggested  that  several  different  micro- 
organisms may  be  capable  of  producing  the  disease.  That  it  is  due  to 
infection  there  is  little  doubt,  from  its  analogy  to  other  infectious  dis- 
eases. It  occurs  in  epidemic  form  every  few  years  in  some  localities. 
These  outbreaks  are  usually  followed  by  two  or  three  milder  epidemics 
following  seasonal  influences.  The  onset  is  sudden,  often  during  good 
health,  with  chill,  fever,  and  other  symptoms  all  favoring  the  view  that 


ACUTE  RHEUMATISM  155 

it  is  due  to  a  specific  organism.  It  has  been  compared  in  many  of  its 
symptoms  to  pyemia,  but  the  suppurative  symptoms  are  absent.  The 
avenue  of  entrance  to  the  system  is  beUeved  to  be  through  the  tonsils 
and  possibly  the  adjacent  mucous  membranes,  for  tonsilitis  and  pharyn- 
gitis are  often  initial  symptoms.  The  recent  investigations  of  Walker 
and  Beaton  support  the  view  of  Poynton  and  Payne  that  the  disease  is 
due  to  a  specific  micrococcus,  possibly  that  first  described  by  Popoff. 

Two  other  theories  have  had  the  support  of  eminent  authorities,  but 
are  now  maintained  by  few.  They  are  the  chemical  theory  and  the 
nervous  theory. 

(i)  The  chemical  theory  refers  the  disease  to  an  excess  of  either  lactic 
or  uric  acid  in  the  blood,  which,  it  is  claimed,  can  always  be  demonstrated 
with  sufficiently  delicate  tests.  But  it  is  claimed,  on  the  other  hand,  that 
these  acids  may  result  from  bacterial  activity,  and  an  excess  of  uric 
acid  is  at  least  not  constant. 

(2)  The  Nervous  Theory. — The  advocates  of  this  theory  regard  the 
joint  lesions  as  trophic  and  a  result  either  of  the  action  of  cold  upon 
the  nerve  centers  or  as  due  to  an  accumulation  of  lactic  acid  in  the 
system,  on  account  of  faulty  metabolism,  which  in  its  turn  is  a  result 
of  disturbances  of  the  nervous  system. 

Climate. — Rheumatism  is  most  prevalent  in  the  temperate  zone  and 
is  favored  by  humidity  of  atmosphere.  The  largest  number  of  cases 
occur  during  the  winter  and  spring,  especially  in  February,  March,  and 
April.  In  many  localities  the  disease  is  endemic,  and  sporadic  cases 
occur  at  all  seasons.  Epidemics  are  seldom  observed  in  the  United 
States. 

The  age  of  greatest  susceptibility  is  from  15  to  30.  The  disease  is 
rare  before  the  tenth  or  after  the  fiftieth  year,  but  young  children  are 
by  no  means  exempt.    Infants  are  occasionally  attacked. 

Sex. — Previous  to  puberty,  rheumatism  is  more  prevalent  in  girls 
than  in  boys ;  in  after-life,  perhaps  on  account  of  greater  exposure,  it 
attacks  men  more  than  women. 

Heredity. — The  influence  of  heredity  is  doubtful.  Different  members  of 
the  same  family  are  not  infrequently  attacked,  and  some  families  appear 
to  be  more  susceptible  than  others,  even  in  successive  generations.  Some 
writers  have  inferred  that  a  systemic  or  local  type  of  vulnerability  is 
transmitted.  An  arthritic  diathesis  is  thought,  especially  by  English 
writers,  to  be  inherited,  on  account  of  which  one  individual  will  acquire 
rheumatism,  another  gout,  and  another,  perhaps,  arthritis  deformans. 
But  this  diathesis  does  not  manifest  itself  to  any  great  degree  in  our 
country.  Occupation  and  social  position  are  more  important,  perhaps, 
since  the  disease  often  follows  exposure  to  cold  and  wet  or  a  sudden 
checking  of  the  excretions  by  change  of  temperature.  Poverty,  with  its 
attendant  deprivations,  and  occupations  necessitating  a  disregard  of 
the  weather  are,  therefore,  influential  in  its  production.  Injury  of  a  joint 
by  direct  violence,  excessive  activity,  or  strain  may  operate  to  localize 
the  disease.  The  infection  is  believed  also  to  be  favored  by  anemia, 
inanition,  nervous  debility,  shock,  and  chronic  alcoholism.  One  attack 
does  not  confer  immunity;  on  the  contrary,  it  renders  the  individual 
more  susceptible  to  future  infection.  Many  individuals  and  some  families 
appear  to  be  immune. 


156  PRACTICE  OF  MEDICINE 

Morbid  Anatomy. — After  death,  changes  are  found  in  the  joints,  in  the 
blood,  and  sometimes  in  the  heart,  but  they  are  not  distinctive  of  the 
disease. 

The  Blood.— T\\t  number  of  red  blood-corpuscles  is  reduced  more  rap- 
idly than  in  any  other  disease.  They  are  often  as  few  as  2,500,000 
or  less  to  the  c.mm.,  and  the  leucocytes  are  more  than  doubled  in  num- 
ber, rarely  reaching  20,000  or  over.  The  quantity  of  fibrin  is  also 
doubled,  closely  resembling  the  condition  found  in  pneumonia,  but  the 
coagulability  of  the  blood  is  diminished  rather  than  increased. 

The  Joints.— T\ie  synovial  membranes  are  swollen  and  hyperemic  and 
frequently  studded  with  fibrin  flakes.  The  joint  fluid  is  turbid  with 
albumin,  fibrin,  and  leucocytes.  Pus  is  rarely  present  in  uncomplicated 
cases.  The  inflammation  sometimes  extends  along  the  tendon  sheaths, 
especially  in  the  hands,  and  may  invade  the  bursae.  Capillary  dilata- 
tions, ecchymoses,  or  extravasations  are  found  on  the  cutaneous,  mucous, 
and  serous  surfaces  in  severe  cases. 

The  Heart— The  frequency  of  heart  involvement  is  diff'erently  esti- 
mated. Some  authors  assert  that  it  occurs  in  from  a  fourth  to  a  third 
of  all  cases,  probably  a  high  estimate.  The  endocardium  of  the  left  side 
is  most  frequently  aff'ected.  The  mitral  cusps,  particularly  along  the  line 
of  contact,  are  swollen  and  covered  with  vegetations  usually  of  the 
simple,  verrucose  kind.  Ulcerative  endocarditis  is  rare.  Contraction 
and  deformity  of  the  valves  remain  after  recovery  from  the  rheumatism. 
Simple  fibrinous  or  sero-fibrinous  pericarditis  is  not  uncommonly  met 
with.    Myocarditis  sometimes  occurs. 

Sympfoms.—Such  prodromes  as  slight  malaise,  headache,  pains  in 
the  joints  or  muscles,  and  slight  tonsihtis  or  pharyngitis  are  some- 
times observed.  These  are  often  absent,  however,  and  the  disease  sets 
in  with  chilly  sensations,  less  often  with  a  distinct  rigor  and  a  rapid 
rise  of  temperature,  often  to  103°  or  104°  F.  (39.5°— 40.0°  C).  At 
the  same  time  one  or  more  of  the  joints  become  swollen,  hot,  red,  ten- 
der, and  very  painful.  The  pulse  becomes  moderately  rapid,  100  or 
over,  but  it  is  usually  full  and  compressible.  Respiration  is  generally 
normal,  or  corresponds  to  the  temperature.  The  disease  reaches  its 
acme,  as  a  rule,  within  the  first  24  hours.  The  temperature  ordinarily 
pursues  a  very  irregular  course,  fluctuating  between  102°  and  104°  F. 
Qg.o°— 40.0°  C).  The  tongue  is  coated,  the  breath  foul,  and  the 
patient  complains  of  thirst.  The  bowels  are  usually  constipated.  A  pro- 
fuse acid  sweat  of  a  peculiarly  sour  odor  is  usually  a  striking  symptom 
in  the  beginning.  Later  the  perspiration  becomes  neutral  or  alkaline 
if  persistent.  Sudamina  often  form  on  the  skin.  The  urine  is  usually 
scant,  highly  acid  in  reaction,  and  deposits  much  uric  acid  on  cooling. 
The  chlorids  may  be  absent.  Albuminuria  may  be  present,  as  in  other 
febrile  conditions.  The  saHva  is  also  highly  acid,  and  an  excess  of  potas- 
sium sulphocyanid  has  been  found  in  it.  The  nervous  phenomena  are 
generally  limited  to  insomnia  and  restlessness.  DeUrium  sometimes 
develops  in  connection  with  hyperpyrexia.  All  these  phenomena  are  in 
some  cases  aggravated  by  large  doses  of  the  salicylates.  So-called  cere- 
bral rheumatism  is  probably  nothing  more  than  a  congestion  of  the 
meninges  due  to  toxic  irritation.  Cerebral  embohsm  rarely  occurs,  and 
probably  only  as  a  result  of  endocarditis.    As  a  rule,  the  patient  lies  on 


ACUTE  RHEUMATISM 


rS7 


his  back,  shrinking  from  the  slightest  motion  on  account  of  the  extreme 
pain  it  occasions,  and  sensitive  to  the  shghtest  jarring  of  his  beci.  The 
knees,  ankles,  elbows,  and  wrists  are  most  frequently  attacked,  some- 
times simultaneously,  but  usually  in  succession.  If  the  disease  begins  in 
one  of  these  joints,  it  may  remain  in  it  for  a  few  hours  or  for  several 
days,  then  suddenly  invade  another  articulation.  The  patient  may  fall 
asleep  with  the  disease  confined  to  the  ankles,  and  awake  to  find  the 
elbows  or  wrists  involved  and  the  original  joints  in  a  state  of  compara- 
tive comfort.  This  migratory  tendency,  as  it  was  regarded  by  the  older 
writers,  is  one  of  the  strongest  characteristics  of  the  disease.  In  extreme 
cases  almost  all  the  larger  joints  are  simultaneously  affected.  The  pha- 
langeal articulations  are  not  often  involved  in  the  first  attack,  and  the 
sternoclavicular  and  maxillary  even  less  frequently.  Subsequent  attacks 
frequently  affect  the  smaller  joints  alone  or  in  connection  with  the  larger. 
The  tendency  to  endocarditis  should  always  be  borne  in  mind,  and  a 
careful  watch  should  be  kept  on  the  heart,  particularly  in  young  patients 
who  have  passed  through  a  previous  attack.  A  murmur  is  often  heard 
at  the  apex  as  in  other  febrile  diseases,  which  is  not  due  to  endocarditis. 

The  course  of  the  disease  is  exceedingly  variable.  If  not  overcome 
by  treatment,  it  usually  lasts  from  20  to  30  days,  then  gradually  sub- 
sides. Relapses  frequently  occur,  and  the  development  of  complications 
anay  prolong  the  illness. 

Subacute  Rheumatism. — This  is  a  common  form  of  the  disease  in 
every  way  similar  to  the  acute  form,  but  milder  in  all  its  features.  It 
may  follow  an  acute  attack,  or  it  may  run  a  subacute  course  from  the 
beginning.  It  is  often  more  persistent  and  less  amenable  to  treatment 
than  the  acute  form  and  the  danger  of  endocarditis  or  pericarditis  is 
almost  as  great. 

Acute  Rheumatism  in  Children.— Children  usually  suffer  from  the  sub- 
acute form  of  the  disease.  Tonsilitis  is  more  frequently  observed  in  the 
beginning  of  an  attack.  Erythema,  cutaneous  nodules,  and  endocarditis 
are  oftener  observed.  The  joint  symptoms  are,  however,  so  slight  in 
some  cases  as  to  be  readily  overlooked. 

Complications  and  SequelcB. — Hyperpyrexia  is  most  frequent  in  the 
first  attack  and  during  the  second  week  of  the  disease.  The  temper- 
ature frequently  reaches  108°  F.  (42°  C.)  or  even  110°  F.  (43.5°  C.) 
in  fatal  cases.  Delirium  is  often  associated  with  it  and  may  deepen 
into  stupor  or  coma,  but  in  many  cases  the  mind  remains  clear.  The 
pulse  is  usually  rapid  and  feeble  and  the  prostration  becomes  extreme. 

Cardiac  Affections. — Endocarditis  is  the  most  serious  and  unfortunately 
one  of  the  most  frequent  complications.  The  liability  to  it  is  propor- 
tionate to  the  number  of  attacks,  but  decreases  with  the  age  of  the 
patient.  The  mitral  valve  segments  are  most  frequently  affected,  the 
aortic  next;  the  pulmonary  and  tricuspid  valves  are  seldom  involved. 
The  most  serious  results  of  the  disease  are  not  generally  realized  until 
the  development  of  chronic  valvular  lesions  and  failure  of  compensation 
have  developed  months  or  years  after. 

Pericarditis  may  occur  independentl}'  or  it  ma}'  be  associated  with 
endocarditis.  It  is  usually  simple,  fibrinous  or  serofibrinous,  but  it 
may  become  purulent,  especiall}''  in  children. 

Myocarditis  is  infrequent,  and  when  present  it  is  generally  associated 


158  PRACTICE  OF  MEDICINE 

with  endocarditis.  It  consists  of  fatty  or  other  degeneration  of  the 
muscle  fibers.    Acute  dilatation  of  the  heart  has  been  observed. 

Catarrhal  pneumo?iia  and  pleurisy  are  sometimes  associated  with  the 
endocardial  disease.  Bronchitis  is  not  uncommon.  Rapidly  fatal  pulmo- 
nary congestion  has  been  observed  in  a  few  instances. 

Cerebral  Complicaiions. — Delirium,  as  already  stated,  is  sometimes  de- 
veloped by  the  high  temperature  or  by  the  action  of  the  toxins.  Coma 
sometimes  succeeds  it  or  may  develop  independently  of  it.  It  frequently 
precedes  the  fatal  termination  of  the  disease  by  only  a  few  hours.  It 
sometimes  develops  after  convalescence  has  begun,  and  is  occasionally 
due  to  uremia. 

Convulsions  seldom  occur.  They  may  precede  the  coma  or  they  may 
occur  independently,  especially  in  alcoholic  subjects. 

Chorea  has  sometimes  been  observed  as  an  associated  disease.  It  is 
not  always  a  result  of  the  rheumatism.  The  joint  pains  and  tenderness 
in  children  affected  primarily  with  choreaare,  perhaps,  of  a  different  nature 
in  some  cases.  Chorea  due  to  embolism  following  rheumatic  endocar- 
ditis may  not  develop  until  weeks  or  months  after  the  attack. 

Cutaneous  Affectio?is. — Sudamina,  erythema,  petechiae,  and  ecchymoses 
may  be  seen.  The  most  interesting  complication  of  this  kind  is  the 
so-called  peliosis  rheumatica.  In  it  purpuric  spots,  with  or  without 
urticaria  or  erythema,  accompany  the  rheumatic  pains.  The  relation 
of  the  affection  to  rheumatism  is  doubtful. 

Subcutaneous  Nodosities. — During  and  after  the  disease,  subcutaneous 
nodules  varying  in  size  from  a  small  shot  to  a  pea,  firm,  but  movable, 
are  in  rare  cases  found  attached  to  the  tendons  of  the  fingers,  hands, 
wrists,  at  the  edge  of  the  patella,  or  over  the  elbows,  maleoli,  scapulae, 
or  spines  of  the  vertebrae,  especially  in  children  and  young  adults.  The 
skin  is  elevated,  but  not  tender.  The)^  develop  rapidly,  especially  when 
chronic  endocarditis  is  present,  and  may  remain  for  months.  They  are 
oftener  seen  in  England  than  in  America  and  are  more  characteristic  of 
gout  and  arthritis  deformans.      (See  Heberden's  Nodosities.) 

Conjunctivitis  and  iritis  often  recur  with  each  rheumatic  attack,  and 
are  amenable  to  the  same  treatment.  Cystitis,  orchitis,  and  other  affec- 
tions of  the  genitourinary  organs,  muscular  atrophy,  thyroiditis,  and 
other  more  or  less  accidental  complications  have  been  noted. 

Gastritis,  profuse  sweating,  insomnia,  delirium,  and  extreme  prostra- 
tion are  sometimes  induced  by  the  alkaline  treatment. 

Diagnosis. — The  intense  painfulness  and  tenderness  of  the  joints,  with 
the  swelling,  wandering  character  of  the  affection,  and  the  high  tem- 
perature, seldom  leave  doubt  as  to  the  diagnosis.  It  is  probably  incor- 
rect to  apply  the  term  rheumatism  to  the  secondary  arthritis  which 
.often  complicates  scarlatina,  pyemia,  and  many  other  acute  diseases, 
since  it  is  doubtless  due  to  a  different  kind  of  intoxication.  It  ma}^ 
usually  be  distinguished  by  the  presence  of  the  causative  infection.  Py- 
emia is  to  be  distinguished  by  the  frequent  chills,  intermittent  character 
of  the  temperature,  the  often  recognizable  suppurative  processes,  and 
by  the  dusky  or  icteric  color  of  the  skin  as  compared  with  the  anemia 
of  rheumatism. 

Gonorrheal  rheumatism  is  generally  confined  to  a  single  joint.  Al- 
though persistent,  it  is  not  accompanied  by  so  great  prostration  or 


ACUTE  RHEUMATISM  159. 

sweating.    A  poly  arthritic  form  occasionally  occurs,  but  the  inflammation 
is  not  confined  to  the  joint,  and  the  swelling  is  generally  fusiform. 

Acute  osteomyelitis  or  necrosis  affecting  the  lower  end  of  the  femur  or 
the  tibia  may  cause  doubt.  In  either  affection,  however,  the  shaft  and 
epiphyses  are  affected,  and  not  the  joints.  Rigors  frequently  occur,  but 
sweats  are  uncommon.  The  constitutional  as  well  as  the  local  symptoms 
are  severe.  An  early  correct  diagnosis  is  extremely  important  for  the 
adoption  of  surgical  treatment. 

Scurvy  with  symptoms  grossly  resembling  rheumatism  has  only  re- 
cently been  recognized  as  a  comparatively  frequent  affection  of  infants. 
It  affects  the  shaft  of  the  bone  and  not  the  joints,  however,  and  it  is 
usually  confined  to  a  single  locality,  often  an  unusual  one  for  rheumatism. 

Gout  is  generally  confined  to  a  single,  small  joint,  especially  the  great 
toe.  When  it  invades  several  large  joints  it  is  difficult  of  distinction. 
The  age,  family  history,  and  habits  of  the  patient  are  of  value,  and 
the  discovery  of  tophi,  little  nodules  about  the  joints,  and  an  excess  of 
uric  acid  in  the  urine  is  distinctive. 

Prognosis. — The  prospect  for  recovery  from  the  immediate  disease  is 
generally  good,  but  the  danger  of  cardiac  complications  and  the  lia- 
bility to  recurrences  months  or  years  after  are  always  to  be  regarded. 
The  joints  generally  recover  completely  without  more  than  temporary 
stiffness.  Acute  cases  may  always  subside  into  a  subacute  form  and 
finally  become  chronic.  Endocarditis  is  usually  followed  by  permanent 
valvular  insufficiency  or  stenosis.  Death,  when  it  occurs  during  an 
attack,  is  generally  due  to  hyperpyrexia,  myocarditis  or  resultant  acute 
dilatation,  pneumonia,  or  pleurisy. 

Treatment. — The  suffering  is  greatly  mitigated  by  placing  the  patient 
upon  a  smooth,  elastic  mattress,  in  a  quiet  room  admitting  sunlight. 
He  should  have  a  flannel  gown  and  should  lie  between  blankets.  Fre- 
quent changes  are  necessary  on  account  of  profuse  sweating.  The  diet 
during  the  febrile  stage  should  be  limited  to  milk  and  fluid  or  semi- 
fluid articles.  The  thirst  demands  an  abundance  of  pure  water  or  lemon- 
ade at  short  intervals.  Broths  and  soups  may  be  given,  but  beef-juice 
should  be  omitted. 

Local  Treatment. — The  joint  should  always  be  kept  warm  and  at 
rest.  This  may  be  done  by  wrapping  it  in  flannel  or  cotton  batting, 
and  fixation  in  a  splint  is  often  of  great  benefit.  Hot-water  bottles 
may  be  applied.  Relief  is  afforded  in  some  cases  by  hot  fomentations 
and  applications  of  chloroform,  aconite,  or  chloral  liniments  and  lotions 
and  in  others  by  cold  compresses  and  ice-bags.  Blisters  often  afford 
relief  when  applied  below  the  affected  joint,  and  the  Paquelin  cautery, 
lightly  applied,  is  probably  better.  But  such  measures  are  not  often 
necessary.  In  mild  cases  an  ointment  of  salicylic  acid  (2  per  cent) 
freely  applied  to  the  affected  joints  is  often  all  that  is  necessary.  Another 
excellent  application  is  composeci  of  equal  parts  of  guaiacol  and  glycerin. 
The  oil  of  wintergreen  (gaultheria)  may  be  applied  pure.  Methyl  sali- 
cylate  (50  to  100  drops)  has  recently  been  recommended. 

Medication. — The  alkaline  treatment  is  almost  universally  employed. 
The  salicylates  are  regarded  by  Striimpell  and  many  other  authorities  as 
specifics  to  such  an  extent  that  the  diagnosis  may  be  called  into  ques- 
tion when  they  fail  to  cure.     Either  the  acid  or  one  of  its  salts  may 


i6o  PRACTICE  OF  MEDICINE 

be  employed.  Salicylic  acid  should  be  given  in  lo-grain  (0.6)  doses,  in 
capsules  or  tablets,  every  hour  until  i  or  2  drams  (4.0 — 8.0)  have 
been  taken.  The  sodium  or  ammonium  salicylate  should  be  given  freely, 
gr.  XV  to  XX  (i.o — 1.25)  every  two  hours,  until  the  pain  is  relieved  or 
physiological  effects,  tinnitus,  vertigo,  or  nausea,  are  produced.  The 
drug  should  always  be  chemically  pure.  Some  prefer  that  made  from 
wintergreen.  Striimpell  advises  giving  a  dose  of  3j  to  3  jss  (4.0—6.0) 
three  times  a  day.  Prompt  relief  from  the  pain  is  generally  afforded. 
The  doses  may  then  be  reduced  in  size  or  in  frequency.  In  many  cases 
the  disease  is  subdued  to  so  great  an  extent  within  two  or  three  days 
that  the  drug  may  be  discontinued.  It  is  chiefly  in  cases  that  fail  to 
respond  promptly  that  a  continued  use  of  the  salicylates  proves  of  no 
benefit.  It  is  ordinarily  considered  better  to  discontinue  their  adminis- 
tration in  any  case  as  soon  as  the  pain  has  been  entirely  relieved,  in 
order  not  to  increase  the  anemia,  which  is  already  rapidly  developing. 
Potassium  bicarbonate  in  20-grain  (1.25)  doses,  given  along  with  the 
sodium  salicylate,  increases  its  action.  It  may  be  continued  after  the 
sodium  salt  has  been  discontinued,  alone  or  with  half-dram  (2.0)  doses 
of  potassium  acetate. 

Disagreeable  effects  are  not  infrequently  produced  by  the  salicylates. 
The  tinnitus  and  deafness  are  often  extremely  annoying  and  may  be 
attended  with  vertigo  and  epistaxis.  Delirium,  dyspnea,  and  a  peculiar 
nervous  stimulation  are  produced  in  some  cases.  Many  patients  object 
to  the  taste,  however  disguised,  and  in  some  it  produces  extreme  nausea. 
These  symptoms  may  be  relieved  in  a  measure  by  sodium  bromid,  gr. 
XX  (1.25);  or  the  oil  of  wintergreen  may  be  employed  in  doses  of  TT[xx 
(1.25)  every  two  hours,  in  milk  or  emulsified  with  mucilage.  Salol  has 
not  proved  efficient  in  the  hands  of  most  observers.  Salophen,  gr. 
XV  (1.0),  has  been  recommended,  but  it  is  inferior  to  the  salicylates. 
Sodium  or  potassium  iodid  is  often  beneficial  as  convalescence  ap- 
proaches. 

It  is  seldom  that  the  salicylates  fail  to  afford  relief  from  the  suffering, 
but  in  some  cases  morphin,  gr.  y^  to  %  (0.008 — 0.016)  hypodermically, 
is  required.  Phenacetin,  gr.  v  to  x  (0.35 — 0,65),  often  affords  relief  and 
aids  the  action  of  the  salicylates. 

Menzer  has  recently  reported  good  results  in  acute  and  chronic  rheu- 
matism from  the  injection  of  a  streptococcus  serum  obtained  from  cul- 
ture on  ascites  fluid  of  micrococci  removed  from  the  tonsils. 

During  convalescence,  iron  and  tonics  should  be  administered  to  over- 
come the  anemia.  The  continued  adminstration  of  iron  sometimes 
appears  to  prevent  a  recurrence  in  persons  subject  to  repeated  attacks. 
The  patient  should  avoid  exposure,  but  fresh  air  and  sunshine  are  bene- 
ficial. The  diet  should  be  nutritious,  but  without  meat  until  conva- 
lescence is  complete.  The  rheumatic  subject  should,  as  a  rule,  indulge 
sparingly  in  nitrogenous  food  and  malt  liquors. 

GONORRHEAL  INFECTION. 

Definiiion. — An  infection  caused  by  the  gonococcus  of  Neisser  and  man- 
ifested by  symptoms  of  general  toxemia  or  of  localized  inflammation, 
especially  in  the  joints. 


GONORRHEAL  INFECTION  i6i 

Etiology. — The  condition  is  due  either  to  the  entrance  of  the  gono- 
coccus  into  the  blood  or  to  the  absorption  of  the  toxins.  It  occurs  in 
about  I  o  per  cent  of  all  cases  of  gonorrhea,  and  is  most  frequently  seen 
in  young  men  the  subjects  of  gonorrheal  urethritis.  It  may,  however, 
occur  in  individuals  of  any  age  or  either  sex  in  the  presence  of  the  spe- 
cific cause.  Taylor  maintains  that  infection  from  urethritis  is  unusual 
until  the  posterior  urethra  has  become  involved.  It  may  result  from  the 
vulvovaginitis  of  children.  Injury  favors  the  localization  of  the  disease 
in  a  joint.  Exposure  to  cold  and  wet  is  not  recognized  as  an  etiological 
factor.  Individual  susceptibility  is  more  important.  The  disease  is 
entirely  independent  of  rheumatism  or  the  rheumatic  diathesis.  The 
gonococcus  has  been  repeatedly  found  in  the  blood,  in  the  affected  articu- 
lations, and  in  the  pericardium  when  involved. 

Morbid  Anatomy. — When  death  results  from  toxemia,  the  changes  are 
those  of  septicemia.  An  original  source  of  infection  is  usually  found  in 
the  urethra  or  possibly  *in  a  suppurating  gland. 

The  Articulations. — Inflammation  and  thickening  of  the  capsular  liga- 
ment and  synovial  membrane  are  the  distinguishing  features.  There 
may  be  much  or  little  effusion  into  the  joint.  The  fluid  is  generally 
turbid  owing  to  the  presence  of  fibrin  and  leucocytes;  suppuration  is 
unusual,  but  is  sometimes  encountered,  particularly  in  the  wrist  and 
knee  joints.  Mixed  infection  with  streptococci,  staphylococci,  or  pneumo- 
cocci  is  not  uncommon.  Hydrarthrosis  occurs,  especially  in  the  knees. 
Edema  is  peculiar  to  the  wrist  and  ankle.  The  inflammation  is  rarely 
limited  to  the  articulation,  but  it  extends  for  a  variable  distance  along 
the  tendon  sheaths  or  periosteum  above  and  below  the  joint.  As  a 
result,  the  joint  has  a  fusiform  appearance.  The  inflammation  is  limited 
to  these  structures  in  some  cases  and  the  joint  is  not  affected.  Fibrous 
thickening  and  adhesions  are  a  more  constant  and  persistent  result  than 
in  acute  rheumatism. 

Clinical  Forms  and  Symptoms. — i.  Septicemic  Form. — This  may  occur 
as  early  as  the  second  week  of  the  primary  gonorrhea,  or  as  a  result 
of  secondary  infections  from  it.  It  may  follow  any  of  the  recognized 
local  lesions  of  the  disease — urethritis,  conjunctivitis,  vaginitis,  endocar- 
ditis, abscess  in  the  prostate  or  other  glands.  The  symptoms  are  those 
of  septicemia  or  pyemia.  There  is  often  a  slight  elevation  of  tempera- 
ture, however,  in  the  beginning  of  a  specific  urethritis,  which  is  not  nec- 
essarily of  this  character. 

2.  Gonorrheal  Arthritis. — The  joint  involvement  does  not  generally 
begin  until  the  fourth  week,  of  a  gonorrhea.  It  has  been  observed,  how- 
ever, in  the  second  or  third  week,  and  after  several  months  have  elapsed 
and  the  urethritis  has  become  chronic.  The  clinical  manifestations  are 
exceedingly  variable  and  most  persistent  in  character.  One  or  many 
joints  may  be  involved.  A  migratory  painfulness  of  the  joint  may  be 
the  only  symptom.  In  other  cases,  several  joints  become  simultaneously 
swollen  and  painful,  as  in  subacute  rheumatism.  There  is  moderate 
fever,  as  a  rule. 

The  typical  acute  gonorrheal  arthritis  is  a  monarthritis.  The  swelling 
is  often  extreme  and  the  pain  severe.  The  fever  may  be  moderate.  Sup- 
puration of  the  joint  occasionally  occurs.  The  disease  may  become 
chronic,  or  it  may  run  a  chronic  course  from  the  start.    The  periartic- 


1 62  PRACTICE  OF  MEDICINE 

ular  form  in  which  the  inflammation  is  confined  to  the  tendon  sheaths 
is  seen  especially  in  the  knee  and  elbow  or  along  the  tendo  achilHs. 

3.  Gonorrheal  Endocarditis.— This  may  occur  as  a  complication  of 
the  other  forms,  or  independently,  even  in  the  absence  of  articular  in- 
volvement. It  is  often  ulcerative  in  character  and  fatal  in  its  result. 
Pericarditis  occasionally  occurs. 

Comp/icaf ions. —Endocarditis,  pericarditis,  and  pleurisy  may  occur. 
Cerebral  complications  have  been  observed.  Bursitis  and  tenosynovitis 
are  not  uncommon.  The  muscles  and  fascia,  especially  of  the  palm  and 
sole,  may  become  infected.    Iritis  is  sometimes  observed. 

Diagnosis.— The  difl'erentiation  between  a  gonorrheal  arthritis  and  an 
intercurrent  rheumatic  arthritis  is  often  impossible  uathout  the  discovery 
of  the  gonococcus  in  the  joint  fluid.  The  diagnostician  may  be  misled 
when  the  patient  denies  the  existence  of  gonorrhea.  The  most  distinctive 
features  of  gonorrheal  arthritis  are  the  involvement  of  but  one  or  at 
most  two  or  three  joints  or  the  absence  of  migrator_y  tendency,  the  fusi- 
form character  of  the  swelling,  the  tendency  to  invade  the  tendon  sheath, 
and  the  extreme  persistence  of  the  disease. 

/Vo^rnos/s.— Notwithstanding  the  persistence  of  the  disease,  ultimate 
recovery  is  the  rule.  A  greater  or  less  degree  of  anchylosis  often  re- 
mains for  a  time.  The  septicemic  form  and  the  pericarditis  may  prove 
fatal.  Recurrence  is  not  unusual,  especially  when  a  fresh  attack  of  gon- 
orrhea is  contracted.    Mixed  infection  adds  gravit}^  to  the  prognosis. 

Treatment— The  thorough  treatment  of  the  primary  source  of  in- 
fection is  important.  The  condition  of  the  posterior  urethra  should  be 
looked  into.  The  salicylates  and  alkahs  are  of  httle  or  no  benefit.  They 
may  be  employed,  however,  when  the  diagnosis  has  not  been  fully  es- 
tablished. Potassium  iodid  has  not  proved  of  value.  The  adminis- 
tration of  tonics,  particularly  of  iron  and  arsenic,  has  proved  the  most 
satisfactory  treatment.  Good  food  and  fresh  air  are  highly  advanta- 
geous. During  the  acute  stage  the  patient  must  be  kept  at  rest  and  the 
joint  should  be  immobilized.  The  hot-air  treatment  has  proved  of  bene- 
fit in  the  later  stages  of  the  disease.  Bhsters,  cauterization,  and  counter- 
irritants  have  been  recommended.  In  persistent  cases  the  joint  cavity 
may  be  aspirated  under  careful  antisepsis,  and  a  1:2500  solution  of 
mercuric  chlorid  or  a  i  150  solution  of  carbolic  acid  may  be  injected. 
If  suppuration  occurs,  vigorous  surgical  measures  must  be  promptly 
adopted. 

SYPHILIS. 

LUES  VENEREA,   THE   POX. 

Def/n/i/on. — A  chronic  infectious  disease,  usually  of  venereal  origin, 
characterized  by  a  great  variety  of  pathological  lesions  and  clinical 
manifestations  corresponding  with  the  stage  of  the  disease  and  the 
part  affected.    It  may  be  hereditary  (congenital)  or  acquired. 

Etiology.— The  specific  cause  has  not  been  definitely  determined. 
The  bacillus  of  Lustgarten  is  often  found  in  the  lesions.  It  is  a  straight 
or  curved  rod  having  slightly  enlarged  ends  and  measuring  3  or  4/i 
in  length.      It  is  probably  the  same  as  that    recently  found    by   Max 


SYPHILIS 


163 


Joseph  in  the  semen  of  syphilitics  and  propagated  by  cultivation  on 
sterile  normal  placenta.  The  disease  is  peculiar  to  man,  and  suscep- 
tibility is  probably  universal. 

I.  Accidental  Infection. — Inoculation  most  frequently  occurs  through 
the  skin  or  mucous  membrane  of  the  genitalia  as  a  result  of  sexual 
congress.  It  may  occur  anywhere  that  the  virus  comes  into  contact 
with  a  tissue  whose  continuity  is  broken.  The  term  syphilis  insontium 
is  applied  to  the  disease  when  innocently  acquired.  The  virus  may  be 
conveyed  by  means  of  such  contaminated  articles  as  drinking-vessels, 
towels,  bed-linen,  rags,  razors,  pipes,  dental  instruments.  It  has  been 
communicated  by  kissing,  tattooing,  vaccination  with  humanized  virus, 
and  the  introduction  of  an  infected  hypodermic  needle.  The  infant  may 
become  infected  by  the  kiss  of  a  syphilitic  person  and  convey  the  virus 
to  the  nipple  of  the  mother.  The  hand  of  the  physician  has  been  in- 
oculated during  surgical  and  obstetric  work. 

'  2.  Inherited  Infection. — This  may  be  transmitted  from  either  parent 
in  whom  the  disease  is  active  at  the  time  of  conception.  Tertiary  syphi- 
lis of  the  parent  does  not  beget  in  the  offspring  active  syphilis,  but  a 
feeble,  cachectic  constitution  with  great  liability  to  mental  defects  and 
physical  deformities.  The  disease  may  be  transmitted  to  the  fetus 
through  the  placenta  when  the  mother  has  become  infected  during  her 
pregnancy. 

Pathology. — The  Chancre. — The  primary  lesion  consists  of  a  circum- 
scribed infiltration  of  the  connective  tissue  with  granulation  and  epithe- 
lioid cells,  with  an  occasional  giant-cell  and  a  few  bacilli,  usually  found 
in  the  center  of  the  infiltration.  Changes  occur  also  in  the  smaller 
blood-vessels,  nerve  fibers,  and  lymph-vessels  immediately  around  it. 

Secondary  Lesions. — These  are  of  the  greatest  variety,  including 
cutaneous  eruptions,  mucous  patches,  condylomata,  affections  of  the 
eye,  nerves,  and  viscera. 

Tertiary  Lesions. — The  lesion  characteristic  of  this  stage  is  the  gumma, 
the  most  distinctive  of  all  syphilitic  formations.  It  belongs  to  the  gran- 
ulomata  and  may  be  either  infiltrating  or  circumscribed  in  character. 
It  may  originate  in  the  connective  tissue  of  any  structure  of  the  body. 
It  consists  of  an  infiltration  of  a  greater  or  less  area  of  the  tissue,  with 
small  round  or  polyhedral  cells  in  which  new  blood-vessels  are  formed. 
Subsequent  changes  lead  to  the .  formation  of  ulcers  in  the  superficial 
tissues  or  to  caseation,  amyloid  degeneration,  or  sclerosis  in  the  inter- 
nal organs.  Large  cutaneous  syphilids  and  vascular  sclerosis  are  com- 
mon features  of  this  stage.    The  lesions  are  usually  symmetrical. 

Sympioms. — Acquired  Syphilis. — The  clinical  manifestations  are  usually 
divided  for  description  into  three  stages,  although  the  line  of  separation 
is  not  always  clearly  defined.  Following  inoculation  there  is  a  period 
of  latency  of  three  or  more  weeks  during  which  there  is  no  evidence 
of  the  disease. 

Primary  Stage. — The  initial  lesion  appears  as  a  small  papule  which 
gradually  enlarges  and  breaks  in  the  center,  to  form  an  ulcer  with  in- 
durated edges.  The  nearest  lymph-glands  become  enlarged  and  indu- 
rated; they  seldom  suppurate. 

Seco7idary  Stage.— T\\\s  begins  with  the  first  evidence  of  constitutional 
involvement,   from   six   weeks  to  three  months  after  the  appearance  of 


1 64  PRACTICE  OF  MEDICINE 

the  chancre.  A  mild  fever  frequently  develops;  it  runs  a  continuous 
course,  seldom  reaching  102°  F.  (38.8°  C),  but  it  is  sometimes  severe 
and  may  run  up  to  104°  F.  (40°  C.)-  Anemia  is  often  an  early  symp- 
tom, the  blood-count  showing  3,000,000  corpuscles  to  the  cubic  milli- 
meter or  less.  In  some  cases  the  integument  assumes  a  slightly  yellow- 
ish, cachectic  hue. 

A  more  or  less  distinct  roseolar  rash  appears  on  the  chest,  abdomen, 
and  anterior  surfaces  of  the  arms,  sometimes  on  the  entire  body,  but 
seldom  on  the  face,  and  persists  from  two  to  three  weeks.  A  papular 
eruption  (papular  syphiUd),  resembling  acne,  sometimes  appears  on 
the  face  and  trunk.  Less  frequently  there  is  a  pustular  rash  which  has 
been  mistaken  for  smallpox,  or  a  squamous  syphilid  resembling  psoria- 
sis, though  less  scaly.  Mucous  patches,  flat  warty  excrescences,  showing 
a  tendency  to  ulcerate,  appear  at  the  same  time  on  the  mucous  membrane 
of  the  mouth,  lips,  tongue,  or  throat,  or  on  moist  surfaces  of  the  skin, 
as  at  the  angles  of  the  mouth.  Cond3'lomata,  warty  outgrowths  of 
the  papillae,  are  often  seen  at  the  junctions  of  the  skin  with  the  mucous 
membranes,  or  upon  surfaces  which  are  kept  moist  by  contact  with 
adjacent  surfaces,  as  in  the  gluteal  and  anal  folds.  The  lymph-glands 
of  the  entire  body  become  more  or  less  indurated.  Deep-seated  osteo- 
scopic  pains  are  complained  of  at  night  during  this  stage,  and  the  an- 
terior surface  of  the  tibia  may  become  slightly  swollen,  roughened,  and 
sensitive  to  pressure.  The  scalp  may  also  become  tender,  and  there  often 
develops  a  point  of  extreme  sensitiveness  to  firm  pressure  near  the  up- 
per end  of  the  sternum. 

Iritis  is  not  uncommon  from  the  third  to  the  sixth  month  of  the 
disease.  Choroiditis,  retinitis,  otitis,  laryngitis,  and  other  inflammatory 
affections  are  sometimes  produced.  The  hair  falls  out,  usually  in  patches, 
sometimes  as  a  general  alopecia,  including  the  eyebrows  and  other  re- 
gions; brittleness  of  the  finger-nails  is  often  observed. 

Tertiary  Stage. — There  is  no  clear  mark  of  distinction  between  this 
stage  and  the  secondary.  It  generally  begins  in  from  three  to  six  months 
after  the  beginning  of  constitutional  infection,  unless  delayed  by  treat- 
ment. It  may  be  preceded  by  a  short  period  of  latency.  The  most 
distinctive  features  are  the  appearance  of  scattered  syphilids  which 
manifest  a  tendency  to  produce  deep  ulcerations,  and  gummatous  growths 
in  the  skin  and  subcutaneous  tissues,  muscles,  and  internal  organs. 
Amyloid  degeneration  and  sclerosis  are  common.  The  internal  lesions 
are  largely  a  result  of  these  processes. 

I.  Digestive  System. — Fissures,  ulcers  (mucous  patches),  or  gummata 
may  form  in  the  tongue,  causing  much  enlargement  and  interference 
with  deglutition.  The  tonsils  may  be  swollen  and  ulcerated,  and  gum- 
mata sometimes  form  in  the  posterior  wall  of  the  pharynx. 

The  esophagus  and  stomach  are  seldom  affected,  but  stenosis  occa- 
sionally results  from  the  pressure  of  large  gummata.  Ulceration  oc- 
curs at  times  in  the  intestine;  symptoms  may  be  absent,  or  there  may 
be  tenderness  and  diarrhea.  The  rectum  is  a  common  seat  of  cicatricial 
stenosis,  especially  in  women.  The  constriction  usually  forms  above 
the  internal  sphincter  and  produces  alternating  constipation  and  diar- 
rhea, often  ribbon-like  stools,  and  reflex  nervous  manifestations. 

In  the  liver  the  disease  is  manifested  by  :  («)   Diffused  hepatitis,  a 


SYPHILIS  165 

small-celled  infiltration  with  hyperplasia  of  the  connective  tissue  pro- 
ducing enlargement  or  contraction;  (/^)  gummata,  sometimes  large 
enough  to  be  recognizable  through  the  abdominal  wall;  (^)  perihepati- 
tis with  thickening  of  the  capsule,  frequently  accompanied  with  pain  and 
tenderness;  and  (^)  amyloid  degeneration  with  marked  enlargement. 
These  conditions  are  frequently  attended  with  slight  icterus,  emaciation, 
ascites,  and  enlargement  of  the  spleen  and  symptoms  on  the  part  of 
other  organs. 

2.  Respiratory  System. — Ulcers  of  the  larynx  sometimes  develop  and 
may  destroy  the  vocal  cords  or  cause  necrosis  of  the  cartilages;  the 
epiglottis  is  sometimes  involved  in  the  destructive  process.  Syphilis 
of  the  lung  is  not  common,  but  gummatous  and  sclerotic  changes  oc- 
casionally occur.  The  lesions  are  usually  confined  to  the  base  and  may 
involve  more  than  one  lobe.  Bronchiectasis  may  result  from  the  cica- 
tricial contraction.  The  symptoms  suggest  tuberculosis,  but  the  disease 
is  of  slow  progress  and  can  generally  be  recognized  by  the  location  in 
the  base,  the  absence  of  tubercle  bacilli,  and  the  history  or  evidences 
of  syphilitic  infection. 

3.  Circulatory  System. — Vegetative  endocarditis,  gummatous  myocar- 
ditis, amyloid  degeneration,  and  fibrous  induration  are  the  usual,  though 
infrequent,  cardiac  lesions.  The  coronary  arteries  may  be  obliterated 
or  aneurism  may  be  produced.  The  arterial  system  is  especially  liable 
to  syphilitic  changes  in  the  nature  of  obliterative  endarteritis.  Arterio- 
sclerosis and  the  formation  of  gummatous  deposits  in  the  adventitia 
are  particularly  frequent  in  the  cerebral  vessels.  Syphilis  is  probably 
the  most  common  cause  of  aneurism. 

4.  Nervous  System. — Either  the  brain  or  the  cord  may  be  affected. 
Gummata  form  especially  in  the  meninges  and  cause,  chiefly  through 
pressure,  a  localized  meningitis,  encephalitis,  or  m.yelitis  with  degenera- 
tive changes  and  softening  of  the  nerve  tissue.  Hemorrhage  is  some- 
times produced.  The  gummata  may,  through  degenerative  changes, 
become  fibrous,  caseous,  cystic,  or  calcareous.  The  symptoms  produced 
are  those  of  tumor  affecting  the  brain  or  cord. 

5.  Renal  System. — The  kidneys  are  also  the  seat  of  gummatous  for- 
mations, producing  symptoms  of  nephritis,  albuminuria,  edema,  some- 
times hematuria.  Amyloid  degeneration  is  not  infrequent,  in  association 
with  the  same  condition  in  other  organs,  especially  the  liver,  intestines, 
and  spleen.  Anemia  and  emaciation  are  prominent  symptoms ;  the  skin 
becomes  waxy.  A  large  quantity  of  clear  urine  is  voided  which  contains 
albumin  and  tube-casts.  Dropsy  and  diarrhea  frequently  contribute 
to  the  inevitably  fatal  course  of  the  amyloid  disease.  The  bladder  is 
not  often  the  seat  of  syphilitic  disease,  but  perforating  ulcers  are  thought 
to  be  sometimes  of  this  nature.  Orchitis  of  a  fibrous  or  gummatous 
nature  sometimes  occurs.    Epididymitis  is  rare. 

Metasyphilitic  Affections.— Syphilis  renders  the  subject  liable  to  cer- 
tain diseases  not  necessarily  of  syphilitic  nature,  as  locomotor  ataxia, 
epilepsy,  paralytic  dementia,  and  pernicious  anemia.  Epilepsy  beginning 
in  adult  life  independently  of  trauma  is  almost  invariably  of  this  char- 
acter. 

Congenital  Syphilis.— The  firstborn  of  syphilitic  parents  is  generally 
premature  and  stillborn.    When,  however,  the  disease  is  present  at  birth 


1 66  PRACTICE  OF  MEDICINE 

in  a  living  child,  it  has  usually  the  form  of  a  vesicular  or  bullous  cuta- 
neous eruption  with  enlargement  of  the  liver  and  spleen.  The  child  is 
feeble  and  emaciated,  has  the  snuffles,  its  lips  are  fissured,  and  the  joints 
may  be  enlarged.  In  other  instances  the  infant  appears  healthy  at 
birth,  and  thrives  for  a  month  or  six  weeks,  then  develops  a  nasal 
catarrh  (syphilitic  rhinitis),  which  interferes  with  its  nursing  and  often 
leads  to  ozena,  necrosis  of  the  nasal  septum,  and  the  production  of  a 
characteristic  deformity.  Other  lesions  soon  appear,  particularly  an 
erythematous,  eczematous,  or  papular  eruption  on  the  nates.  The  child 
becomes  weak  and  emaciated.  It  is  often  restless  and  sleepless  at  night. 
Its  cry  is  feeble  and  high  pitched  on  account  of  the  weakness ;  the  face 
appears  old  and  wrinkled.  Gastrointestinal  disturbances  often  develop 
and  hasten  the  termination  of  the  unfortunate  life. 

The  child  sometimes  survives,  but  it  never  becomes  vigorous.  At  the 
age  of  twenty  years  it  has  often  the  appearance  of  twelve  (infantilism). 
The  skin  is  sallow,  the  hair  scant,  and  the  teeth  deformed.  The  upper 
central  incisors  are  notched,  short,  and  wedge-shaped,  narrower  at  the 
cutting  edge  than  at  the  gum  (Hutchinson  teeth).  The  cranium  and 
the  long  bones  are  often  deformed ;  the  forehead  is  usually  broad.  Owing 
to  a  congenital  weakness  of  blood-vessel  walls,  large  blue  dilated  veins 
are  often  seen  upon  the  head  and  neck.  Many  other  lesions  peculiar 
to  the  disease,  but  not  confined  to  the  congenital  form  of  it,  are  often 
observed  in  the  later  life  of  these  subjects. 

Diagnosis. — The  features  which  distinguish  the  primary  sore,  or  chan- 
cre, are  its  appearance  not  less  than  three  weeks  after  the  inoculation, 
its  round  or  slightly  oval  shape  varying  in  size  from  a  split  pea  to  that 
of  a  ten-cent  piece,  its  red  and  indurated  edges,  and  the  absence  of 
spreading  ulceration.  The  chancroid  is  differentiated  by  its  earlier  ap- 
pearance, irregular  shape,  flat  edges,  and  early  ulceration.  The  syphi- 
litic sore  is  single;  there  may  be  several  chancroids.  The  chancroidal 
bubo  suppurates,  but  there  are  no  other  secondary  lesions.  The  sec- 
ondary lesions  of  syphilis  are  typical,  especially  when  a  history  of  the 
primary  sore  can  be  obtained.  In  women,  however,  this  is  often  impos- 
sible. A  roseolar  eruption  with  mucous  patches  and  enlargement  of  the 
lymph-glands,  with  moderate  fever  or  normal  temperature,  can  rarely 
be  attributed  to  any  other  affection. 

The  chief  difficulty  is  encountered  in  the  diagnosis  of  the  visceral 
lesions  of  the  tertiary  period.  Unfortunately  the  results  of  direct  inter- 
rogation are  less  to  be  relied  upon  than  in  any  other  disease.  The 
syphilitic  will  lie  to  his  own  hurt,  and  condemn  the  physician  who  ac- 
cepts his  statement  as  true.  Women  are  frequently  innocent  victims, 
and  it  is  often  wrong  to  arouse  a  suspicion  of  their  condition.  In  such 
cases  the  diagnosis  must  often  be  based  upon  the  history  of  a  roseolar 
rash,  mucous  patches,  sore  throat,  possibly  an  iritis,  as  an  evidence  of 
which  a  contracted  pupil  may  remain.  There  is,  perhaps,  a  history  of 
nocturnal  osteoscopic  pains,  loss  of  hair,  a  paronychia  of  several  fingers, 
and  there  may  have  been  one  or  more  miscarriages.  Examination  may 
reveal  cicatrices  in  the  mouth,  throat,  the  inguinal  region,  or  over  the 
tibia,  a  deformed  or  perforated  palate.  The  earlier  cutaneous  lesions 
are  symmetrical  in  location;  the  later  are  not  always  so.  The  tertiary 
rupia  produces  characteristic,  prominent  crusts  resting  upon  deep  ulcers. 


SYPHILIS  167 

The  vesicular  lesions  of  syphilis  when  found  upon  the  hands  are  often 
confined  to  the  palms ;  when  on  the  feet,  to  the  soles ;  they  do  not  itch. 
These  features  exclude  papular  eczema  and  other  itching  eruptions.  Acne 
is  accompanied  by  comedones,  and  the  sores  are  confined  to  the  seba- 
ceous follicles.    They  are  less  inflamed  and  do  not  form  ulcers. 

Congenital  Syphilis. — The  appearance  of  snufiles  and  a  cutaneous 
eruption  on  the  nates  of  a  child  within  the  first  three  months  is  not 
to  be  mistaken  for  any  other  disease.  Later  the  anemia,  emaciation, 
the  peculiarly  aged  facics,  especially  if  accompanied  with  enlarged  joints 
and  wedge-shaped  teeth,  are  pathognomonic. 

The  therapeutic  test.,  made  by  the  administration  of  large  doses  of 
potassium  iodid,  is  of  greater  value  in  the  cutaneous  than  in  the  vis- 
ceral forms  of  the  disease.  The  drug  is  well  borne  by  a  syphilitic  patient 
and  causes  rapid  improvement  of  the  condition,  but  the  test  is  not  in- 
fallible. 

Prognosis. — The  prognosis  is  good  in  the  early  stages,  except  in  alco- 
holic or  cachectic  patients  or  those  debilitated  by  age  or  disease.  Much 
depends  upon  beginning  the  treatment  early.  Recovery  is  often  complete 
after  three  years'  treatment.  The  recovery  should  not  be  regarded  as 
permanent,  however,  until  at  least  one  year  has  elapsed  without  a 
reappearance  of  the  symptoms  after  the  discontinuance  of  medication. 

When  treatment  is  begun  in  the  later  stage  and  when  relapse  occurs 
during  persistent  treatment,  little  hope  can  be  entertained  of  ultimate 
recovery.  One  of  the  most  difficult  questions  which  frequently  confront 
the  physician  is  that  of  the  marriage  of  the  syphilitic.  This  should  be 
unconditionally  condemned  until  at  least  a  year  has  passed  without 
relapse  and  without  medication.  It  were  better,  indeed,  that  syphilitics 
never  married. 

The  prognosis  of  inherited  syphilis  is  always  bad.  The  earlier  the 
disease  appears  the  less  is  the  prospect  of  life. 

Prophylaxis. — Syphilis  is  theoretically  a  preventable  disease  and  one 
that  could  be  eradicated.  Practically  it  is  not  so.  Few  problems 
have  received  so  much  study  from  the  beginning  of  the  world  to  the 
present  time  as  that  of  the  social  evil,  but  the  solution  is  not  yet.  The 
systematic  inspection  of  prostitutes  has  proved  only  partially  successful. 
Much  of  the  difficulty  arises  from  the  recklessness  of  .young  men  during 
the  early  stages  of  the  disease.  It  is  the  duty  of  the  physician  to  warn 
his  patient  of  the  certainty  of  communicating  the  disease  by  contact 
or  by  the  use  of  the  same  drinking-cups,  towels,  or  other  articles.  The 
criminality  of  voluntarily  or  carelessly  communicating  the  disease  to 
another  should  be  impressed  upon  his  mind. 

Treatment. — The  primary  sore  requires  little  treatment  further  than 
cleansing  and  the  application  of  calomel  or  other  dry  powder  twice  or 
thrice  daily.  It  is  customary  with  most  physicians  to  delay  the  consti- 
tutional treatment  until  the  diagnosis  has  been  fully  established  by  the 
appearance  of  secondary  manifestations.  WTien  this  has  been  done,  it 
is  less  difficult,  as  a  rule,  to  convince  the  patient  of  the  correctness  of  the 
diagnosis  and  of  the  necessity  of  continued  treatment  after  the  disease 
has  been  gotten  under  control.  As  soon  as  the  roseolar  rash  has  ap- 
peared, however,  the  most  energetic  treatment  should  be  instituted. 

Mercury  and  potassium  iodid  are  specific  remedies.      The  former  is 


1 68  PRACTICE  OF  MEDICINE 

especially  valuable  in  the  secondary  stage,  the  latter  in  the  later  mani- 
festations of  the  disease.  The  iodids  of  mercury  are  much  employed, 
however,  during  the  tertiary  period. 

Inunction  Treatment. — It  is  generally  best  to  begin  the  treatment 
with  mercurial  inunction.  One  dram  of  mercurial  ointment  should  be 
rubbed  into  the  skin  for  a  half-hour  or  longer  every  evening  for  two 
or  three  weeks,  substituting  a  warm  bath  for  the  inunction  every  fifth 
or  sixth  evening.  The  sides  of  the  chest  and  abdomen  and  the  inner 
surfaces  of  the  arms  and  thighs,  places  where  the  skin  is  thin,  should 
be  selected  on  successive  evenings. 

Internal  Treatment. — Mercury  may  be  administered  by  the  mouth. 
The  blue  pill  (massa  hydrargyri)  or  mercury  v/ith  chalk  (hydrargyrum 
cum  creta)  may  be  given  in  dose  of  i  grain  (0.06),  preferably  combined 
with  ^  or  ^  grain  (0.008  or  0.016)  of  opium  to  prevent  catharsis. 
The  mercuric  chlorid  is  employed  in  doses  of  1-40  to  1-20  (0.0016 — 
0.0032);  the  protiodid  ^  grain  (0.016),  or  the  biniodid,  gr.  1-20  in- 
creasing to  1-12  (0.003  to  0.005). 

The  subcutaneous  treatment  is  sometimes  to  be  preferred.  The  mer- 
curic chlorid  is  generally  employed,  ^  grain  (0.02)  being  injected  deep 
into  the  gluteus  or  other  muscle  once  a  week.  One  or  two  grains  (6.06— 
0.13)  of  calomel  in  20  minims  (1.23)  of  glycerin,  or  ten  drops  of  a 
mixture  of  equal  parts  of  metallic  mercury  and  lanolin  containing  2 
per  cent  of  carbolic  acid,  may  be  injected  in  the  same  manner. 

Fut7iigation  is  seldom  employed  in  this  country.  For  its  administra- 
tion the  patient  is  placed  on  a  chair  having  a  perforated  seat,  then 
covered  with  a  blanket.  Perspiration  is  started  by  the  heat  from  a 
spirit  lamp  placed  under  the  chair.  After  this  has  been  accomplished, 
3  ss  (2.0)  of  calomel  is  vaporized  by  placing  it  in  a  spoon  and  holding 
it  over  the  alcohol  flame.  The  patient  then  goes  to  bed  wrapped  in  the 
blanket. 

In  the  later  stages  of  the  disease,  potassium  iodid  is  most  relied  upon. 
It  should  be  given  in  doses  of  from  15  to  30  grains  (i.o — 2.0)  or  more, 
well  diluted,  three  times  a  day  for  several  months  at  a  time.  When  the 
result  is  not  altogether  satisfactory,  the  dose  may  be  increased  so  long 
as  iodism  is  not  produced,  or  the  mixed  treatment  may  be  employed,  com- 
bining about  1-40  grain  (0.0016)  of  the  mercuric  chlorid  with  10  to 
15  grains  of  the  potassium  iodid.  The  action  of  the  iodid  is  increased 
by  giving  it  in  a  large  draught  of  hot  water.  Some  physicians  occa- 
sionally interrupt  the  treatment  with  the  potassium  iodid  by  giving 
one  of  the  iodids  of  mercury. 

Whatever  the  plan  adopted,  the  treatment  should  be  continued  with- 
out interruption  for  fully  a  year.  An  occasional  interval  of  a  week 
without  treatment  may  then  be  allowed.  Two  years  of  treatment  is 
the  minimum  of  time  required  for  a  cure;  three  years  of  persistent 
medication  is  much  safer. 

Treatment  of  Hereditary  Syphilis. — Mercurial  treatment  of  the  mother 
during  her  pregnancy  is  of  benefit  to  the  child  and  may  enable  it  to 
survive.  The  infant  may  be  nursed  by  the  mother  when  she  is  in  physi- 
cal condition  to  provide  it  with  nourishment,  since  it  is  a  well-known 
law  (CoUes's  law)  that  the  mother  does  not  become  inoculated  even  if 
not  previously  syphilitic;  but  it  must  never  be  given  to  the  wet-nurse, 


TUBERCULOSIS  169 

for  it  will  surely  inoculate  the  nipple.  The  subsequent  treatment  of  the 
infant  is  based  on  the  same  principles  as  that  of  adults.  Calomel  or 
mercury  and  chalk  may  be  given  in  doses  of  i-io  grain  (0.006)  t.  i.  d. 
Inunctions  or  baths  are  a  less  cei^tain  mode  of  introducing  the  mercury 
into  the  system.  For  lesions  corresponding  to  those  of  the  tertiary 
period,  the  iodids  or  the  mixed  treatment  should  be  employed.  The 
sirup  of  the  iodid  of  iron  is  an  excellent  remedy  in  these  cases,  since 
it  counteracts  also  the  anemia. 

The  administration  of  tonics,  particularly  of  iron  and  codliver  oil, 
is  advantageous  in  advanced  cases.  Cases  that  have  persistently  resist- 
ed vigorous  specific  treatment  not  infrequently  begin  a  rapid  improve- 
ment after  resort  to  these  remedies. 

Precautions. — During  treatment  with  mercury  the  patient  should 
abstain  from  alcohol  and  tobacco  and  he  should  not  eat  freely  of  acid 
fruits  and  salads.  The  mouth  and  teeth  should  be  cleansed  after  each 
meal,  preferably  with  a  5  per  cent  solution  of  potassium  chlorate.  Upon 
the  first  indication  of  ptyalism — an  increased  flow  of  saliva,  soreness 
of  the  gums,  fetid  breath,  or  diarrhea — the  mercury  must  be  discontinued 
for  a  few  days.  When  symptoms  of  iodism  appear — coryza,  headache, 
drowsiness,  acne,  erythema,  or  albuminuria — this  remedy  must  be  given 
in  reduced  doses  or  temporarily  discontinued. 


TUBERCULOSIS. 

Tuberculosis  is  the  most  universal  of  all  diseases,  prevailing  in  all  parts  of  the  world 
at  all  seasons  and  among  all  races.  It  attacks  also  many  of  the  lower  animals.  Among 
domestic  animals  it  is  most  frequent  in  cattle,  next  in  young  swme;  sheep,  horses,  dogs, 
and  cats  are  less  frequently  attacked.  Fowls  and  fish  are  not  exempt.  Wild  animals 
are  seldom  affected,  but  when  domesticated  they  become  exceedingly  susceptible  to  it. 
Rats  and  mice  acquire  the  disease.  Among  human  beings  it  is  more  destructive  than 
all  the  other  communicable  diseases  combmed,  causing  14  per  cent  of  the  entire  mortal 
ity.  This  fact  affords  only  a  partially  correct  idea  of  its  prevalence,  however,  for  many 
tuberculous  persons  die  of  other  diseases,  and  the  lesions  are  often  found  after  death  in 
those  who  were  not  known  to  be  affected  during  life.  The  mortality  from  it  in  different 
countries  corresponds  very  closely  to  the  population.  Every  organ  and  every  tissue  of 
the  body  is  liable  to  the  disease,  but  the  lungs  are  more  frequently  attacked  than  any 
other  structure.  It  is  customary,  therefore,  to  regard  tuberculosis  as  a  general  affection 
having  localized  lesions. 

I.    GENERAL   TUBERCULOSIS. 

Definition. — An  infectious  disease  caused  by  the  bacillus  tuberculosis 
of  Koch,  the  entrance  of  which  leads  to  the  formation  of  tubercles  or 
to  diffused  infiltrations  of  tubercular  tissue  that  frequently  undergo 
subsecjuent  caseation  or  sclerosis,  and  sometimes  calcification. 

Etiology. — The  Bacillus. — The  bacillus  tuberculosis,  discovered  by  Koch, 
in  1 88 1,  is  the  specific  cause  of  tuberculosis  in  all  of  its  many  mani- 
festations. The  disease  can  be  produced  by  no  other  organism.  The 
bacillus  is  a  slender,  nonmotile,  aerobic  rod,  measuring  from  1.5  to 
4,a  in  length.  It  is  often  found  in  clusters.  Branching  forms  are  ex- 
ceptionally seen,  and  it  has  sometimes  a  beaded  appearance  in  stained 
preparations,  which  has  been  incorrectly  attributed  to  the  presence  of 
spores.      Probably  the  most  distinctive  feature  of  the  bacillus    is    the 


I70  PRACTICE  OF  MEDICINE 

slowness  with  which  it  takes  up  the  analin  stains  and  its  equal  reluc- 
tance to  part  with  them,  even  under  the  influence  of  mineral  acids  of 
sufficient  strength  to  decolorize  all  other  bacteria.  It  is  cultivated  with 
some  difficulty,  growing  best  on  blood  serum  and  only  at  a  tempera- 
ture of  37°  C.  It  is  often  overcome  in  cultures  by  the  more  exuberant 
growth  of  other  bacteria,  but  within  the  body  it  is  remarkably  hardy, 
growing  luxuriantly  in  the  presence  of  staphylococci,  streptococci,  and 
other  organisms.  Exposure  in  water  to  a  temperature  of  60°  C.  de- 
stroys it  in  15  minutes,  although  it  is  capable  of  resisting  ordinary 
desiccation  for  months.  Cold  has  no  effect  upon  it.  The  rays  of  the 
sun  are  fatal  to  it  within  from  15  minutes  to  several  hours  according 
to  the  season  and  the  character  of  the  sputum  or  other  substance  in 
which  it  is  embedded.  Diffuse  daylight  near  a  window  is  said  to  de- 
stroy its  vitality  within  a  week.  The  bacillus  is  believed  to  be  strictly 
a  parasite,  as  it  is  not  known  to  find  conditions  suitable  for  its  propa- 
gation outside  of  the  body  of  a  living  animal,  except  in  culture-media. 

The  recent  investigation  of  the  apparent  relation  of  the  tubercle  ba- 
cillus to  the  ray  fungus  of  actinomycosis,  although  properly  belonging 
to  the  department  of  bacteriology,  is  of  much  interest  in  this  connec- 
tion. It  has  been  found  that  when  this  bacillus  has  been  passed  through 
the  bodies  of  such  cold-blooded  animals  as  the  frog,  it  adapts  itself 
better  to  a  saprophytic  existence,  growing  vigorously  upon  artificial 
media  at  ordinary  temperatures,  while  its  virulence  is  reduced.  Regu- 
larly branching  forms,  sometimes  producing  threads,  are  commonly 
seen.  As  Lubarsch  suggests,  the  appearance  is  that  of  a  reversion  to 
an  original  saprophytic  state.  Similar  branching  forms  have  been  found 
upon  grass  and  in  cow's  dung.  The  question  is  therefore  raised  by  Hek- 
toen  whether  the  tubercle  bacillus  may  not  be  a  parasitic  form  of  some 
of  these  organisms  closely  related  to  the  ray  fungus  and  existing  natu- 
rally upon  grass  and  elsewhere.  The  case  of  streptothrix  bronchitis  re- 
ported by  Musser  seems  to  support  this  theory. 

Chemical  Products. — The  bacillus  yields  a  series  of  chemical  products 
regarding  the  nature  of  which  comparatively  little  is  known.  The  most 
important  are  the  fluid  and  precipitated  toxin,  the  aqueous  tuberculin, 
best  known  in  the  form  of  Koch's  tuberculin,  which  is  a  glycerin  ex- 
tract, and  the  fat-free  bacilli  obtained  by  precipitation.  An  albumose 
and  a  ptomain  have  also  been  isolated. 

The  virulence  of  the  bacillus  is  very  different  when  the  latter  is  ob- 
tained from  different  sources  or  when  it  is  propagated  on  different  cul- 
ture-media.    Prolonged  cultivation  causes  marked  reduction  of  virulence. 

Distribution  of  Bacilli. — The  bacilli  may  be  found  in  the  blood  in  acute 
tuberculosis,  in  the  sputum  when  the  respiratory  passages  are  involved^ 
in  the  urine,  feces,  and  other  discharges  from  tubercular  foci.  They  are 
found  also  in  all  tubercular  lesions,  their  numbers  corresponding  closely 
to  the  activity  of  the  disease.  In  the  lymph-glands  and  other  structures 
in  chronic  tuberculosis  they  may  be  unrecognizable  by  staining  methods, 
although  they  still  respond  to  cultivation  and  inoculation  into  the  lov/er 
animals. 

Modes  of  Infeciion. — In  a  great  majority  of  cases  the  disease  is  un- 
doubtedly communicated  directly  or  indirectly  from  person  to  person. 
To  what  extent  tuberculous  animals  contribute  to  the  dissemination  of 


TUBERCULOSIS  171 

the  disease  among  human  beings  is  still  a  matter  of  discussion.  Cattle 
are  looked  upon  by  some  writers  as  important  sources  of  infection, 
particularly  through  their  flesh  and  milk,  notwithstanding  the  fact 
that  Koch  has  questioned  the  possibility  of  the  transmission  of  bovine 
tuberculosis  to  man.  The  immediate  avenue  of  invasion  is  in  a  majority 
of  cases  the  respiratory  passages,  but  the  infection  may  be  hereditary 
or  it  may  occur  under  favorable  conditions  through  any  of  the  cuta- 
neous or  mucous  surfaces  of  the  body.  The  infective  agent  is  generally 
acquired  through  inhalation,  ingestion,  or  inoculation. 

I .  Hereditary  Transmission. — There  are  three  ways  in  which  the  trans- 
mission of  tuberculosis  from  parent  to  offspring  is  theoretically  possible, 
namely  :  {a)  By  the  sperm,  (J>)  by  the  ovum,  and  (<:)  the  blood  of  the 
mother  through  the  placental  circulation.  Tubercle  bacilli  have  been 
found  in  the  semen,  but,  as  Osier  remarks,  the  chances  are  extremely 
small  that  the  bacillus  should  lodge  in  the  individual  spermatozoon 
which  fecundates  the  ovum,  and  they  appear  still  smaller  when  we  con- 
sider that  the  spermatozoon  is  made  up  of  nuclear  material  which  the 
tubercle  bacillus  is  never  known  to  attack.  No  case  has  been  recorded 
in  which  hereditar}^  transmission  from  the  father  was  an  inevitable  con- 
clusion from  the  facts  in  the  case. 

The  same  objections  are  almost  equally  applicable  to  the  theory  of 
transmission  through  the  ovum,  for  it  is  almost  inconceivable  that  the 
ovum  should  survive  the  entrance  of  the  bacillus.  Baumgarten,  however, 
detected  a  bacillus  within  the  ovum  of  a  rabbit  which  he  had  artificially 
impregnated  with  tubercular  semen.  That  the  fetus  may  become  in- 
fected from  the  blood  of  a  tuberculous  mother  is  possible,  and  the  view 
that  such  infection  occurs  is  supported  by  the  fact  that  tubercular 
lesions  have  been  found  in  the  fetus.  It  is  not  an  accident  which  is  Hkely 
to  occur  often,  however,  for  the  bacilli  are  rarely  found  in  the  general 
circulation  except  in  the  rapidly  fatal  miliary  form  of  the  disease  or  as 
a  result  of  the  perforation  of  a  blood-vessel  by  a  tubercular  infiltration. 
It  is  claimed  by  some  writers  that  the  placenta  is  always  tubercular  in 
these  cases,  and  tubercles  have  been  found  in  it  in  several  instances. 
But  the  value  of  all  these  speculations  is  minimized  by  the  statement 
of  Hahn,  that  only  20  authentic  cases  of  congenital  tuberculosis  have 
been  recorded.  In  nearly  all  cases  regarded  as  congenital  a  period  of 
two  weeks  or  more  has  elapsed  between  the  birth  of  the  infant  and  the 
discovery  of  the  disease.  There  is  a  possibility,  therefore,  that  infection 
of  the  infant  may  have  occurred  through  inhalation  or  ingestion  of  bacilli 
during  the  first  days  of  hfe.  The  bacilli  are  often,  no  doubt,  implanted 
upon  the  hps  of  the  infant  through  the  kisses  of  the  tuberculous  mother 
or  through  the  application  of  her  handkerchief  to  its  face. 

Those  who  still  hold  to  the  doctrine  that  tuberculosis  is  to  any  great 
extent  inherited  maintain  that  the  bacilli  in  many  instances  remain 
dormant  in  the  body  for  a  great  length  of  time  and  ultimately  become 
active  when  the  individual's  power  of  resistance  is  in  some  way  lowered. 
In  this  regard  the  disease  is  comparable  to  syphiHs,  which  frequently  ej^- 
hibits  this  type  of  latency.  The  comparison  does  not  hold,  however, 
when  we  reflect  that  tuberculosis  frequently  passes  over  the  second  gen- 
eration, to  appear  in  the  third,  a  fact  which  is  not  easily  accounted  for 
on  the  theory  of  latency. 


172 


PRACTICE  OF  MEDICINE 


There  can  be  no  doubt  that  a  vulnerable  type  of  constitution  is  often 
transmitted  to  the  offspring  of  tuberculous  parents,  and  it  is  highly 
improbable  that  anything  more  than  this  is  ordinarily  handed  down. 
And  when  we  add  to  this  enfeeblement  of  the  power  of  resistance,  the 
constant  exposure  of  the  infant  to  the  many  sources  of  infection  from 
the  tuberculous  mother,  we  perhaps  fully  account  for  the  frequent  devel- 
opment of  the  disease  during  the  first  years  of  life. 

2.  Inhalation  of  dust  to  the  particles  of  which  bacilli  have  become 
adherent  is  probably  the  most  prolific  source  of  infection.  The  dust 
becomes  contaminated  for  the  most  part  through  the  expectoration 
of  consumptive  persons,  but  the  sputum  itself,  after  drying,  and  be- 
coming pulverized,  may  be  carried  by  currents  of  air.  The  extent  to 
which  infection  is  possible  through  the  medium  of  the  sputum  becomes 
apparent  when  we  reflect  upon  the  enormous  prevalence  of  the  disease 
and  the  incomprehensible  number  of  bacilli  which  each  tuberculous  per- 
son is  capable  of  producing.  As  estimated  by  Vaughan,  one  person  in 
every  60,  or  1,050,000,  of  the  entire  population  of  the  United  States  is 
tuberculous,  and  Nuttall  estimates  that  each  tuberculous  individual 
may  throw  off  from  one  and  a  half  to  more  than  four  billions  of  bacilli 
in  24  hours.  Examination  of  the  dust  from  the  walls,  floor,  and  furni- 
ture of  apartments  occupied  by  consumptives  almost  invariably  reveals 
the  presence  of  large  numbers  of  virulent  bacilli.  The  air  of  such  apart- 
ments, especially  after  sweeping  and  "  dusting,"  contains  them.  Guerard 
reports  the  occurrence  of  541  cases  in  248  dwellings  in  a  single  ward 
of  the  tenement  district  of  New  York  city,  in  which  there  was  a  total 
of  663  dwellings.  Tuberculosis  has  repeatedly  been  introduced  and  has 
become  prevalent  in  regions  which  had  previously  been  exempt  from  it, 
by  the  arrival  of  those  affected  with  it.  Health  resorts  are  converted 
into  hotbeds  of  the  disease  to  a  considerable  extent  by  the  infection  of 
the  original  inhabitants.  Our  Indian  tribes  were  free  from  tuberculosis 
until  the  arrival  of  the  white  man ;  a  part  of  their  present  susceptibility 
must,  however,  be  attributed  to  the  adoption  of  civilized  manners  of 
dissipation. 

The  universal  dissemination  of  the  disease  through  the  contamination 
of  the  air  is  largely  attributable  to  carelessness.  The  danger  of  infection 
could  be  greatly  diminished  through  proper  disposal  of  the  sputum. 
It  appears,  in  fact,  that  the  disease  has  become  slightly  less  prevalent 
as  a  result  of  the  more  general  dissemination  of  the  knowledge  that  a 
tuberculous  person  is  a  source  of  danger  to  those  who  come  into  contact 
with  him.  The  breath  of  the  consumptive  is  not  in  itself  infective,  but 
in  coughing  and  sneezing,  even  in  talking  (Fliigge),  these  persons  throw 
off  fine  particles  of  sputum  so  minute  that  they  float  in  the  air.  The 
inspiration  of  these  particles  is  a  possible  source  of  infection  to  another 
person.  Fliigge,  indeed,  regards  this  as  a  more  positive  means  of  trans- 
mitting the  disease  than  the  inhalation  of  dry  dust. 

3.  Ingestion. — This  mode  of  infection  is  usually  considered  with  especial 
reference  to  the  ingestion  of  the  meat  or  milk  of  tuberculous  cattle. 
But  it  is  probable  also  that  the  bacilli  often  gain  entrance  to  the 
alimentary  canal  through  the  contamination  of  other  articles  of 
food,  for  example  through  virus  carried  by  flies  or  other  insects.  The 
danger  of  infection  through  the  eating  of  tubercular  meat  is  compara- 


TUBERCULOSIS  173 

tively  small,  since  it  would  be  possible  only  when  the  bacilli  were  actually 
present  in  the  flesh  consumed  and  when  they  escaped  destruction  by  the 
processes  of  cooking  and  digestion.  Koch  aroused  much  discussion  by 
his  statement  at  the  British  Congress  of  Tuberculosis,  in  1901,  that 
the  danger  of  the  transmission  of  bovine  tuberculosis  to  man  is  very 
slight.  He  estimated  the  extent  of  infection  by  the  milk  and  flesh  of 
tuberculous  cattle  as  hardly  greater  than  that  from  hereditary  trans- 
mission. The  comparative  frequency  of  primary  intestinal  tuberculosis 
in  young  children  is  attributed  chiefly  to  the  drinking  of  milk  containing 
bacilli.  It  has  been  found  that  these  may  be  present  in  the  milk  of  an 
animal  whose  udder  is  perfectly  healthy  and  in  which  the  disease  is 
dormant  to  such  a  degree  that  it  can  be  recognized  only  by  the  tuber- 
culin test.  It  should  be  remembered  also  that  the  grass  bacilli  closely 
resemble  those  of  tuberculosis  and  cannot  be  distinguished  by  the  usual 
staining  test. 

Demme  records  an  interesting  observation  that  illustrates  the  cer- 
tainty of  deglutition  infection  from  the  entrance  of  the  bacilli  of  human 
tuberculosis.  Four  infants  died  in  succession  of  primary  tuberculosis  of 
the  intestine,  under  the  care  of  a  nurse  who  was  suffering  from  tuber- 
culosis of  the  jaw,  with  a  iistulous  opening  into  the  mouth.  It  was 
found  that  the  nurse  was  in  the  habit  of  placing  the  food  for  infants  in 
her  own  mouth  before  giving  it  to  them. 

Deglutition  infection  is  also  a  common  form  of  autoinoculation 
among  pulmonary  tuberculous  patients.  Intestinal  tuberculosis  com- 
monly develops  during  the  late  stages  of  the  disease  as  a  result  of  the 
swallowing  of  sputum. 

4.  Inoculation. — The  disease  is  seldom  communicated  by  direct  inocula- 
tion; and  when  this  docs  occur,  the  resultant  infection  usually  remains 
localized.  Any  broken  surface  of  the  skin  may  become  inoculated.  It 
is  therefore  a  not  infrequent  result  of  injury  to  the  hands  in  post-mor- 
tem work  (the  post-mortem  wart).  It  is  seen  also  on  the  hands 
of  those  who  handle  and  wash  the  clothing  and  other  articles  of  the 
tuberculous  patient.  It  is  interesting  to  note,  also,  that  such  inoculation 
is  by  no  means  uncommon  among  farmers,  butchers,  and  tanners  who 
handle  the  meat  and  hides  of  infected  cattle,  and  that  veterinary  sur- 
geons have  repeatedly  been  inoculated  from  diseased  cattle.  Inoculation 
has  less  frequently  been  produced  through  the  piercing  of  the  ears, 
tattooing,  and  the  bite  of  a  tuberculous  person.  It  has  repeatedly  fol- 
lowed the  rite  of  circumcision,  the  final  act  of  which  is  the  sucking  of 
the  v/ound ;  tubercle  bacilli  have  been  demonstrated  in  several  instances, 
both  in  the  wound  and  in  the  mouth  of  the  operator.  Inoculation  of 
tuberculosis  has  been  attributed  also  to  sexual  intercourse. 

Predisposing  Jnfliiences. — Inherited  vulnerability  of  constitution  is  per- 
haps not  of  so  great  importance  as  it  was  formerly  believed  to  be.  The 
tendency  since  the  discovery  of  the  specific  germ  of  tuberculosis  has  been 
to  minimize  the  importance  of  heredity.  It  is  generally  stated,  however, 
that  a  history  of  tuberculosis  among  the  ascendants  of  the  patient  is 
found  in  at  least  25  per  cent  of  cases  when  the  parents  alone  are  con- 
sidered, and  in  about  60  per  cent  when  the  grandparents  also  are  taken 
into  account.  It  is  believed  that  the  vulnerability  of  type  is  more 
certainly  handed  down  by  the  mother  than  by  the  father.     Some  families 


174  PRACTICE  OF  MEDICINE 

show  a  more  or  less  continuous  prevalence  of  the  disease  through  five 
or  six  generations,  but  on  the  other  hand  it  would  be  difficult  to  find 
a  family  which  had  passed  through  so  many  generations  without  ac- 
quiring the  taint.  So  much  depends  upon  the  environments  of  the 
individual,  his  nutrition  and  habits  of  life,  and  above  all  upon  exposure 
to  infection,  however,  that  the  influence  of  heredity  will  probably  remain 
indefinite.  It  has  frequently  been  observed  that  children  which  have 
been  removed  from  the  parents  and  placed  under  good  conditions  have 
escaped  the  disease  while  those  that  remained  with  the  tuberculous 
parent  have  become  infected. 

Individual  Peculiarities . — The  "  phthisical  habit"  has  been  recognized 
since  the  time  of  Hippocrates,  yet  the  disease  is  not  uncommon  among 
persons  of  robust  frame  and  free  from  the  white  skin,  blue  eyes,  trans- 
parent conjunctivae,  and  winged  scapulas  which  are  regarded  as  typical 
of  tuberculous  tendency.  The  long  and  flat,  or  narrow,  thorax,  with  a 
straightness  of  the  upper  ribs  and  an  obliquity  of  the  lower,  conditions 
unfavorable  to  the  full  expansion  of  the  lungs,  are  not  without  influence. 
But  the  "scrofulous  frame"  is  now  regarded  only  as  an  indication  of 
vulnerability.  More  important  from  an  etiological  standpoint,  perhaps, 
is  the  tendency  to  catarrhal  inflamimation  so  often  seen  in  these  individ- 
uals, which  Beneke  attributes  to  imperfect  development  of  the  heart 
with  hypertrophy  of  the  whole  arterial  system,  the  pulmonary  artery 
being  relatively  wider  than  the  aorta  and  thus  favoring  increased  intra- 
pulmonary  blood-pressure. 

Environment. — The  influence  of  environment  becomes  apparent  not 
only  in  those  individuals  who  live  in  an  atmosphere  charged  with  tuber- 
cular virus,  but  to  almost  as  great  an  extent  in  those  who  are  deprived 
of  sunlight  and  fresh  air.  Animals  allowed  to  run  free  in  the  open  air 
after  inoculation  with  tubercular  virus  sometimes  recover,  while  those 
that  are  confined  in  a  dark,  damp  atmosphere  quickly  succumb;  and 
the  same  is  true  of  human  beings.  It  is  due  largely  to  the  influence  of 
environment  that  the  disease  is  more  prevalent  in  large  cities  than  in 
the  country,  and  among  the  poor  rather  than  among  those  in  comfor- 
table circumstances.     Bad  food  adds  to  the  evil  effects  of  bad  hygiene. 

Climate  and  Season. — Climate  and  season  influence  to  some  extent  the 
development,  and  yet  more  the  progress,  of  the  disease.  This  influence 
is  probably  inferior,  however,  to  that  of  the  sunlight  and  fresh  air,  or 
the  cold,  wet,  and  temperature-changes  that  belong  to  all  climates. 
Devitalized  air — air  that  has  been  breathed  over  and  over  again  in  small, 
unventilated  sleeping-apartments — undoubtedly  exerts  a  powerful  in- 
fluence in  the  production  of  susceptibility  to  infection.  The  disease  is 
less  prevalent,  it  is  in  fact  almost  unknown,  in  a  few  sparsely  settled 
mountainous  or  desert  regions,  but  this  is  due  probably  more  to  the 
absence  of  the  infectious  agent  or  to  the  outdoor  life  of  the  inhabitants 
than  to  the  climate.  A  region  which  proves  beneficial  to  strangers  will 
not  always  confer  immunity  upon  its  inhabitants.  Many  regions  have 
from  time  to  time  been  pronounced  free  from  the  disease,  but  at  the 
present  time  the  ratio  of  cases,  to  the  population  of  any  district  is  very 
nearly  the  same  in  all  parts  of  the  world. 

Age. — The  influence  of  age  is  recognizable  rather  in  the  tendency  to 
the  involvement  of  certain  structures  than  in  the  general  susceptibility 


TUBERCULOSIS  175 

to  infection,  for  no  age  is  exempt  from  the  disease.  During  infancy  and 
childhood  the  bones,  lymph-glands,  meninges,  and  intestines  are  more 
frequently  attacked.  From  the  fifth  to  the  tenth  year,  which  is  usually 
the  period  of  greatest  outdoor  activity,  there  appears  to  be  a  lull  in 
the  development  of  the  disease.  From  15  to  40  we  see  the  pulmonary, 
pleuritic,  laryngeal,  and  peritoneal  forms,  and  in  more  advanced  life 
fibroid  phthisis. 

Sex. — Women  are  somewhat  more  frequently  attacked  than  men. 
But,  aside  from  the  influence  of  indoor  life  common  to  women  and  the 
probable  influence  of  pregnancy  and  lactation  in  lowering  the  power  of 
resistance,  there  is  little  or  no  difference  in  the  susceptibility  of  the  sexes. 

Race.—Oi  all  races,  the  Hebrew  is  the  most  nearly  immune.  The 
Irish  are  extremely  susceptible.  Among  negroes  in  our  country  the 
disease  is  becoming  more  prevalent  and  more  fatal. 

Occupation. — Those  constantly  confined  to  small,  dark  rooms  and  to 
a  sitting  posture,  as  tailors  and  shoemakers,  or  those  much  exposed  to 
the  vicissitudes  of  the  weather  are  more  frequently  attacked  than  others. 
Occupations  which  necessitate  the  inhalation  of  dust,  as  those  of  grinders 
and  polishers,  stonecutters  and  coal  miners,  predispose  by  the  constant 
irritation  of  the  respiratory  passages. 

Alcoholism. — Chronic  alcoholism  lowers  the  resisting  power  and  is  an 
especially  potent  factor  in  those  whose  constitution,  environment,  and 
occupation  are  already  favorable  to  infection. 

Disease. — Bronchial  catarrh  is  one  of  the  most  frequent  conditions 
precedent  to  tuberculosis.  The  sequence  of  whooping-cough,  measles,  or 
influenza,  bronchitis,  bronchopneumonia,  and  tuberculosis  is  often  ob- 
served. A  catarrhal  condition  of  the  pharynx  or  tonsils  favors  infection, 
especially  in  children.  Smallpox  and  syphilis  are  also  thought  to  in- 
crease susceptibility.  And  tuberculosis  frequently  bears  the  relation  of 
a  terminal  infection  to  diabetes,  valvular  disease  of  the  heart,  aneurism, 
hepatic  or  renal  cirrhosis,  and  other  for  the  most  part  chronic  debili- 
tating afi"ections.  Cancer  and  tuberculosis,  at  one  time  thought  to  be 
antagonistic  to  each  other,  have  more  recently  been  found  associated, 
not  only  in  the  same  person,  but  even  in  the  same  organ. 

Trauma. — Injury  of  the  lungs,  meninges,  or  bone,  and  more  partic- 
ularly of  the  joints  favors  the  localization  of  the  disease  in  them. 
And  injury  or  operation  on  a  tuberculous  joint  has  not  infrequently 
been  followed  by  a  dissemination  of  the  disease  and  the  development  of 
miliary  tuberculosis. 

Morbid  Anatomy  of  Tubercle. — After  the  tubercle  bacilli  have  gained 
entrance  into  the  tissues  they  rapidly  multiply.  The  irritation  of  the 
tissues  by  the  toxins  results  in  the  production  of  tubercles,  small  nodular 
granulomatous  formations,  not  characteristic,  but  so  common  to  this 
disease  as  to  have  given  it  the  name  tuberculosis.  Tubercles  are  there- 
fore a  result  rather  than  a  part  of  the  disease-process.  The  formation 
of  a  tubercle  consists  :  (i)  In  the  proliferation  of  cells  from  the  endothe- 
lium of  the  blood-  and  lymph-vessels,  perhaps  also  from  epithelium,  pro- 
ducing epithelioid  cells,  in  which  the  iDacilli  may  usually  be  seen;  (2) 
around  this  an  infiltration  of  leucocytes  from  the  blood-vessels  of  the 
vicinity.  (3)  Giant-cells  usually  appear  among  the  infiltrated  cells, 
their  number  generally  standing  inversely  to  that  of  the  bacilli  present. 


X76  PRACTICE  OF  MEDICINE 

(4)  A  reticulum  is  formed  from  the  fibrous  tissue  of  the  region  and 
constitutes  the  external  zone  of  the  tubercle.  Almost  the  entire  process 
of  tubercle-formation  may  be  regarded  as  an  effort  on  the  part  of  the 
system  to  shut  off  the  bacilli  from  the  surrounding  tissues.  The  nodule 
is  not  provided  with  blood-vessels,  hence  its  nutrition  is  poor,  and  degen- 
erative changes  soon  occur.  The  most  common  change  is  caseation, 
but  sclerosis  or  calcification  is  not  unusual. 

Caseation  begins  at  the  center  of  the  tubercle  and  invades  the  entire 
nodule.  When  several  tubercles  lie  in  proximity,  it  may  extend  to  the 
entire  mass.  Calcification  is  a  subsequent  change  and  consists  in  the 
deposit  of  lime  salts  in  a  tubercle  which  has  undergone  caseation. 

Sclerosis  affects  especially  the  outer  zone,  but  the  entire  mass  may 
be  converted  by  it  into  a  firm,  fibrous,  scarlike  tissue.  Caseation  is  a 
destructive  process;  sclerosis  is  constructive.  The  former  tends  to  the 
formation  of  cavities ;  the  latter  to  the  limitation  and  final  destruction 
of  the  tubercular  process.  The  tubercle  which  is  visible  to  the  naked 
eye  consists  of  a  collection  of  small  miliary  tubercles,  of  microscopic  size, 
or,  as  they  are  sometimes  called,  submiliary  tubercles. 

Tubercular  TnJiltration.~T\\^  entrance  of  bacilli  is  not  invariabl}^ 
followed  by  the  formation  of  distinct  tubercles;  for  in  some  cases  it 
produces  a  diffuse  inflammation.  Microscopic  examination  of  the 
involved  areas  shows  numerous  non-vascular  collections  of  cells  without 
distinct  nodular  arrangement,  the  only  separation  being  a  round-celled 
infiltration.  These  large  collections  of  cells  may  be  the  result  of  the 
coalescence  of  many  smaller  areas  of  infection.  Coagulation  necrosis 
soon  follows  their  formation,  and  a  large  area  of  caseation  (the  so-called 
caseous  pneumonia)  is  the  result.  This  condition  is  most  frequent  in 
the  lungs  and  the  area  affected  may  be  small  or  large,  involving  only 
a  few  lobules  or  an  entire  lobe. 

Distribution  of  Tubercles. — Tubercles  may  be  found  in  every  structure 
of  the  body  except,  perhaps,  the  teeth.  The  skin,  subcutaneous  tissue,  the 
cancellous  tissue  of  bone,  and  the  mucous  membranes,  especially  of  the 
respiratory  passages,  but  not  seldom  those  of  the  alimentary  and 
genitourinary  tracts;  the  serous  and  synovial  membranes  and  the 
pia  mater  are  frequent  locations.  Among  organs,  the  lungs  are  most 
frequently  affected,  but  the  liver,  spleen,  kidneys,  testes,  and  lymph- 
glands  are  often  attacked.  The  dura  mater,  ependyma,  and  endocardium 
are  seldom  affected.  The  brain,  spinal  cord,  adrenals,  and  prostate  are 
also  among  the  less  frequently  affected  regions,  and  the  heart,  salivary 
glands,  pancreas,  the  mammae,  ovaries,  thyroid,  and  voluntary  muscles 
are  among  the  rarest  of  all  locations.  The  secondary  changes  are  also 
to  a  great  extent  peculiar  to  certain  regions.  Caseation  is  most  frequent 
in  the  lungs  and  lymph-glands;  calcification  is  common  in  the  lymph- 
glands,  but  less  so  in  the  lungs.  Sclerosis  is  sometimes  found  in  the 
pulmonary  tubercles,  but  it  is  more  common  to  those  of  the  peritoneum. 

From  the  original  focus  the  tubercular  virus  is  distributed :  (a) 
Directly  to  the  contiguous  tissue  or  through  the  lymph-vessels;  (^)  in 
the  lung  also  by  aspiration,  the  infective  material  being  drawn  into 
bronchi  which  were  previously  unaffected;  and  (r)  through  veins  and 
arteries  whose  walls  have  been  infiltrated  or  perforated,  often  producing 
general  miliary  infection. 


Practice  of  Medicine— French. 


PLATE 


i,:^'-^}.  .:''^,  Mrs  ^'t-\*:-C. 


Miliary  Tuberculosis  (Acute)  of  the  Lung. 

The  miliary  tubercles,  small  and  irregular  in  shape,  are  distributed 
throughout  the  lung — more  abundantly  in  the  upper  and  middle 
thirds. 

The  blood-vessels  are  injected  with  blue  gelatin,  so  that  in  this 
photographic  reproduction  of  the  specimen  the  uninvolved  portions  of 
lung  are  dark,  while  the  tubercles — in  which  the  blood-vessels  are 
compressed  or  obliterated — are  light. 

(Bjy  permission,  from  "Delafield  and  Prudden.") 


TUBERCULOSIS  177 

Secondary  Inflammatory  Process. — The  inflammation  excited  by  the 
presence  of  the  bacilli  in  the  tissues  is  not  always  limited  to  the  produc- 
tion of  tubercles,  for,  beyond  the  nodular  mass,  there  is  frequently  a 
proliferation  of  cells,  with  the  production,  in  the  lungs,  of  fibrinous  or 
catarrhal  pneumonia;  or  a  proliferation  of  fibrous  tissue  and  the  pro- 
duction of  so-called  fibroid  phthisis;  in  the  blood-  and  lymph-vessels 
degenerative  changes  are  often  produced.  Mixed  infection  is  common,  and 
the  result  is  generally  suppuration.  A  sterile  cold  abscess  is  not  infre- 
quently formed  without  the  entrance  of  pyogenic  micro-organisms,  doubt- 
less as  a  result  of  the  irritation  by  the  tubercle  toxin. 

I.  ACUTE  TUBERCULOSIS. 

Acute    Miliary    Tuberculosis,    General    Tuberculosis,    Acute    Disseminated 

Tuberculosis. 

Definition.  — A  rapidly  fatal  acute  tuberculous  infection  due  to  the  dis- 
semination of  bacilli  through  the  blood-vessels  and  lymphatics,  with  the 
production  of  countless  miliary  tubercles  in  various  organs  and  tissues. 

Etiology. — This  form  of  the  disease  is  almost  always  a  result  of  auto- 
infection,  often  from  a  focus  which  is  not  recognizable  during  life.  This 
focus  is  most  frequently  found  in  the  lungs,  pleura,  lymph-glands,  bones, 
joints,  or  kidneys;  but  nowhere  more  uniformly  than  in  the  tracheal 
and  bronchial  glands.  Ponfick  found  it  in  the  wall  of  the  thoracic  duct, 
and  Weigert  traced  it  in  several  instances  to  the  perforation  of  a  caseous 
bronchial  gland  into  the  pulmonary  vein.  A  similar  communication 
between  a  tubercular  lymph-gland  and  a  vein  has  been  repeatedly  dem- 
onstrated. 

The  disease  occurs  more  frequently  in  children  than  in  adults.  In 
some  cases  the  general  infection  is  so  sudden,  particularly  when  it 
follows  an  acute  infection  like  measles  or  whooping-cough  in  a  pre- 
viously healthy  child,  that  it  is  not  easily  accounted  for.  A  more  or 
less  prolonged  attack  of  bronchial  catarrh  very  often  intervenes  between 
the  two  infections. 

Morbid  Anatomy. — The  tubercles  may  be  so  uniformly  distributed 
that  almost  every  organ  and  tissue  of  the  body  is  involved ;  as  a  rule, 
however,  they  are  more  numerous  in  some  regions  than  in  others.  The 
lungs,  bronchi,  liver,  spleen,  kidneys,  and  lymph-glands,  the  pleura, 
pericardium,  peritoneum,  and  m.eninges  are  commonly  affected,  sometimes 
also  the  choroid  coat  of  the  eye,  the  bone  marrow,  especially  that  of 
the  sternum,  ribs,  and  vertebrae.  The  tubercles  are  for  the  most  part 
small,  from  1-500  to  1-250  inch  in  diameter.  They  are  usually  discrete, 
but  they  sometimes  form  large  aggregations  distinctly  visible  to  the 
naked  eye.  They  do  not  show  secondary  changes,  as  a  rule,  for  the 
progress  of  the  disease  is  so  rapid  that  there  is  no  time  for  such  changes. 
(See  Plate  11.) 

Symptoms.— Acute  general  toxemia  is  the  most  striking  feature  of 
the  disease.  There  is  sometimes  a  predominance  of  symptoms  on  the 
part  of  the  lungs,  cerebral  meninges,  peritoneum,  or  other  structure, 
corresponding  to  an  equally  predominant  invasion  of  these  regions  by 
the  tubercles  and  giving  rise  to  more  or  less  distinct  forms  of  the  dis- 


178  PRACTICE  OF  MEDICINE 

ease,  as  the  pulmonary,  meningeal,  peritoneal,  etc.  They  all  belong  to 
the  same  general  infection  of  the  system,  however,  and  the  local  lesions 
merely  add  a  few  special  features  to  the  general  symptomatology. 

(i)  General  or  Typhoid  Form. — The  invasion  is  generally  slow,  often 
so  similar  to  that  of  typhoid  fever  as  to  lead  to  a  suspicion  of  that 
disease.  After  gradually  increasing  malaise,  headache,  loss  of  appetite, 
constipation,  and  perhaps  chilliness,  the  temperature  gradually  rises  to 
103°  or  104°  F.  (39.5° — 40°  C);  prostration  rapidly  ensues,  and  anemia 
and  emaciation  soon  follow.  The  pulse  becomes  accelerated,  often  to 
140  or  more,  and  the  respiration  is  rapid  and  labored,  often  from  60 
to  80  in  children.  Cheyne-Stokes  respiration  often  develops  toward  the 
end.  The  cheeks  are  flushed,  and  the  face  often  becomes  dusky.  The 
tongue  is  dry,  often  brown;  and  delirium  of  a  quiet,  muttering  type 
may  early  develop.  There  is  usually  a  slight  cough,  due  to  bronchitis. 
In  some  cases,  the  onset  is  more  sudden.  The  irregularity  of  the  fever 
is  a  distinctive  feature  of  the  condition.  The  morning  remission  usually 
amounts  to  2°  or  3°  F.  (1° — 1.5°  C),  but  occasionally  the  fever  is  inter- 
mittent and  the  temperature  in  the  morning  may  be  subnormal.  On 
the  other  hand  it  is  not  uncommon  to  find  the  morning  record  higher 
than  that  of  the  evening.  Rarely  there  is  very  slight  fever  throughout 
the  disease,  and  afebrile  cases  have  been  described.  Albumin  and  pepton 
are  found  in  the  urine.  Sudamina  are  frequent  and  an  eruption  of  herpes 
is  often  found  upon  the  lips.  As  the  disease  progresses,  the  patient 
sinks  into  a  stupor ;  diarrhea  may  develop,  with  involuntary  evacuations, 
and  cyanosis  often  becomes  extreme.  Occasionally,  however,  the  mind 
remains  clear  to  the  end. 

(2)  Pulmofiary  Form. — In  this  form,  symptoms  indicating  the  especial 
involvement  of  the  lungs  are  added  to  those  just  described.  The  cough 
is  more  annoying;  it  has  often  existed  for  several  months  before  the 
acute  onset.  There  is  usually  a  mucopurulent  expectoration,  sometimes 
containing  traces  of  blood.  Hemoptysis  occasionally  occurs.  Dyspnea 
develops  early,  and  cyanosis  may  be  a  prominent  feature  from  the  start ; 
the  blueness  of  the  lips  and  nails  is  often  striking.  The  physical  evidences 
of  pulmonary  involvement  are  not  so  great  as  might  be  anticipated. 
Areas  of  distinct  dullness  are  exceptional.  The  percussion  note  may 
seem  to  lack  resonance,  but  this  condition  is  not  confined  to  any  region 
of  the  chest,  and  there  is  no  means  of  comparison.  In  children  a  slight 
dullness  may  be  detected  at  the  base  of  the  lung,  or  areas  of  increased 
or  slightly  tympanitic  resonance  may  suggest  the  presence  of  solidifica- 
tion in  other  areas.  Auscultation  usually  reveals  sibilant  or  subcrep- 
itant  rales.  Tubular  breathing  may  also  be  heard.  The  spleen  usually 
becomes  enlarged  toward  the  close  of  the  disease. 

Diagnosis. — The  leading  points  of  differentiation  in  the  general  form 
of  the  disease  are  the  absence  of  localized  lesions,  the  irregular  tempera- 
ture, rapid  pulse  and  respiration,  marked  dyspnea,  possibly  cyanosis, 
and  the  rapid  progress  of  the  disease. 

In  typhoid  fever  the  temperature  is  more  regular,  the  respiration 
less  rapid  and  free  from  marked  dyspnea  or  cyanosis.  Epistaxis  fre- 
quently occurs  in  the  beginning,  and  diarrhea  is  more  frequent.  The 
diazo  reaction  is  common  to  both  diseases,  but  the  rose-spots  are  very 
rarely  seen  in  tuberculosis,  and  when  seen  they  do  not  occur  in  successive 


TUBERCULOSIS  lyg 

crops  and  are  not  typical  in  form.  Herpes  is  more  frequent  in  tuber- 
culosis, and  the  tubercles  may  be  found  in  the  choroid.  The  lesions  of 
typhoid  fever  and  tuberculosis  may,  however,  be  found  in  the  same 
person.  The  Widal  test  is  the  most  valuable  means  of  differentiation  in 
a  doubtful  case.  The  presence  of  leucocytosis  favors  tuberculosis,  but 
depends  upon  the  existence  of  suppuration  in  either  disease. 

In  the  pulmonary  form  the  diagnosis  is  usually  rendered  less  difficult 
on  account  of  the  tuberculous  history  in  the  family,  the  existence  of  a 
cough  before  the  present  illness,  possibly  also  a  recent  attack  of  mea- 
sles, whooping-cough,  or  influenza;  and  the  bacilli  may  often  be  demon- 
strated in  the  sputum. 

Malaria. — It  is  only  the  remittent  form  that  resembles  tuberculosis. 
The  temperature  is  more  regular,  as  a  rule ;  but  the  greater  enlargement 
of  the  spleen  and  the  presence  of  the  plasmodium  in  the  blood  are  more 
reliable  features. 

Cerebrospinal  Meningitis. — In  this  disease  the  pulse  and  respiration 
are  usually  less  rapid,  the  onset  is  more  sudden,  and  the  nervous  mani- 
festations, hyperesthesia,  nystagmus,  and  disturbance  of  the  reflexes 
are  more  prominent.  Kernig's  sign  is  not  present  in  acute  tuberculosis 
unless  the  meninges  are  distinctly  involved. 

Capillary  bronchitis  may  simulate  acute  tuberculosis  in  the  beginning, 
but  the  pulse  and  respiration  are  not  so  rapid;  dyspnea  is  less  marked 
and  the  cough  more  troublesome.  The  fever  does  not  usually  become 
so  high,  and  the  prostration  is  not  so  great. 

2.  ACUTE  MENINGEAL  TUBERCULOSIS. 

Basilar  Meningitis,  Acute  Hydrocephalus. 

Definition. — A  form  of  acute  tuberculosis  in  which  the  cerebral  me- 
ninges are  especially  involved. 

Etiology. — Fully  50  per  cent  of  all  cases  of  miliary  tuberculosis  affect 
the  meninges.  The  causes  of  this  form  are  therefore  the  same.  It  is 
seen  much  more  commonly  in  children  between  the  ages  of  two  and 
seven,  but  may  occur  at  any  time  of  life.  It  usually  follows  an  involve- 
ment of  the  bronchial,  mesenteric,  or  other  lymph-glands  or  of  the 
middle  ear,  and  there  may  be  a  history  of  trauma.  In  some  cases,  how- 
ever, the  affection  of  the  meninges  appears  to  be  the  primary  lesion. 
It  has  been  suggested  that  the  bacilli  may  reach  the  meninges  in  such 
cases  through  the  cribriform  plate  of  the  ethmoid.  The  ten  cases  of 
acute  tuberculosis,  mostly  of  the  meninges,  reported  by  Reich  are  of 
interest  in  this  connection,  since  the  disease  followed  the  mouth-to- 
mouth  resuscitation  of  stillborn  children  by  a  tuberculous  midwife. 

Morbid  Anatomy.— The  membranes  of  the  base  are  primarily  and 
chiefly  involved,  but  the  tubercles  may  extend  to  all  parts  of  the  brain. 
The  parts  about  the  optic  chiasm,  along  the  larger  blood-vessels  and 
nerve-trunks,  and  over  the  tempero-sphenoidal  lobes  are  especial  points 
of  attack.  Less  frequently  the  lesions  are  found  on  the  convexities  of 
the  hemispheres.  The  pia  is  intensely  hyperemic  and  the  blood-vessels 
are  all  engorged.  The  walls  of  the  vessels  are  not  infrequently  invaded 
by  the  tubercles,  and  thromboses  sometimes  result.    The  surface  of  the 


i8o  PRACTICE  OF  MEDICINE 

pia  is  usually  covered  with  a  turbid,  viscid,  serous  or  fibrinopurulent 
exudate,  and  miliary  tubercles  are  more  or  less  profusely  distributed  over 
the  affected  surfaces.  The  lateral  ventricles  usually  become  distended 
with  fluid,  sometimes  amounting  to  several  ounces  (acute  hydroceph- 
alus), and  as  a  result  the  hemispheres  may  become  flattened.  The 
ependyma  may  be  softened  and  the  septum  lucidum  and  fornix  may  be 
broken  down.  The  brain  substance  becomes  edematous  and  infiltrated 
with  leucocytes.  Red  softening,  rarely  white,  and  punctiform  hemor- 
rhages are  found.  The  association  of  acute  and  chronic  tuberculosis  of 
the  meninges  has  been  observed.  In  some  cases  the  spinal  meninges, 
especially  in  the  cervical  portion,  have  been  found  extensively  involved. 
The  other  structures  of  the  body  are  always  involved  in  the  disease. 

Symptoms. — There  is  generally  a  history  of  tuberculosis  in  the  family 
and  of  a  recent  attack  of  measles  or  other  acute  infection,  followed 
during  several  weeks  or  months  by  a  gradual  decline  of  health.  During 
the  week  or  two  preceding  the  acute  onset  of  the  aff'ection  there  is  often 
a  complete  change  in  the  disposition  of  the  child.  It  has  become  peevish, 
fretful,  perhaps  quarrelsome;  the  appetite  has  been  lost  and  emaciation 
has  become  apparent.  The  course  of  the  disease  is  divided  into  three 
stages,  embracing  a  period  of  nervous  excitement,  a  transition,  and  a 
stage  of  paralysis. 

(i)  Sfage  of  Excitement. — The  onset  is  usually  gradual,  often  with  a 
basilar  headache,  which  increases  in  severity  until  it  becomes  agonizing. 
Persistent  vomiting  without  regard  to  the  ingestion  of  food  is  a  marked 
feature,  and  there  is  usually  moderate  elevation  of  temperature,  seldom 
exceeding  102°  or  103°  F,  (39-o°^-39.5°  C).  At  first  on  account  of 
pain,  but  later  on  account  of  contraction  of  the  cervical  muscles  the 
head  sinks  into  the  pillow.  Very  often  the  child  grasps  its  head  between 
its  hands  as  if  in  great  pain.  Every  now  and  then  a  loud  shrill  cry, 
known  as  the  hydrocephalic  cry,  is  uttered.  In  some  cases  the  child 
screams  continuously  for  days,  or  until  the  voice  is  lost  from  hoarseness 
and  exhaustion.  Obstinate  constipation  is  a  characteristic  symptom, 
but  diarrhea  sometimes  occurs  in  young  infants. 

The  course  of  the  fever  is  irregular.  The  evening  record  frequently 
exceeds  the  morning  by  3°  or  4°  F.  (1.5° — 2.2°  C).  The  pulse,  at  first 
rapid,  becomes  slow  and  feeble ;  generally  irregular.  The  respiration 
may  be  little  disturbed.  The  sleep  is  restless  and  may  be  disturbed  by 
muscular  twitchings  or  nervous  starts,  and  the  child  often  awakes  in 
terror.    The  pupils  are  usually  contracted  during  this  stage. 

Occasionally  the  onset  is  more  violent  with,  perhaps,  a  convulsion, 
rapid  rise  of  temperature,  and  maniacal  delirium,  sometimes  leading  to  a 
fatal  termination  within  a  few  days.  These  cases  are  more  frequently 
encountered  in  adults  or  in  children  who  have  been  for  a  long  time 
tuberculous.  They  are  as  a  rule  associated  with  involvement  of  the  con- 
vexity of  the  brain.  Cases  are  also  encountered  in  which  the  disease 
pursues  a  more  chronic  course,  marked  by  psychical  disturbances  of  a 
type  that  may  arouse  suspicion  of  a  brain  tumor.  Convulsions  and 
paralyses  do  not  appear  until  a  late  period. 

(2)  Transitional  Stage. — The  symptoms  of  irritation  subside  and 
there  may  be  a  deceptive  promise  of  recovery.  The  vomiting  ceases 
and  the  headache  is  no-  longer  complained  of,  but  the  child  remains  dull 


TUBERCULOSIS  i8i 

and  listless.  It  may  even  become  delirious  at  night.  The  constipation 
persists,  and  the  abdomen  becomes  retracted  and  boat-shaped  (scaph- 
oid). The  temperature  is  variable,  but  seldom  exceeds  102°  F.  (39°  C). 
The  pulse  is  still  irregular  and  the  respiration  is  often  broken  by  sighs. 
The  retraction  of  the  head  persists,  and  opisthotonos  is  not  uncom- 
mon. The  hydrocephalic  cry  is  occasionally  uttered.  The  pupils  are 
dilated  or  uneven;  one  large,  the  other  small.  Strabismus  or  ptosis  may 
develop  from  paralysis  of  the  extrinsic  muscles.  Tubercles  may  be  found 
in  the  choroid  coat  of  the  eye.  Livid  spots  of  considerable  size  may 
appear  in  the  face,  and  a  red  line  (tache  ce'rebrale,  or  Trousseau's  mark) 
appears  in  the  skin  after  the  finger-nail  has  been  drawn  over  it,  but  this 
is  not  characteristic  of  the  disease.  Convulsions  sometimes  occur,  or 
the  muscles  of  one  side  or  of  a  single  member  may  become  either  rigid 
or  paralytic!  A  tetanic  spasm  sometimes  seizes  a  single  limb,  and  it 
may  persist  for  several  days.  Choreic  movements  and  tremors  are  not 
unusual. 

(3)  Stage  of  Paralyses.— h.  progressively  deepening  coma  supervenes 
until  the  child  can  no  longer  be  aroused.  Convulsions  may  still  occur ; 
and  when  the  meninges  of  the  cortical  motor  area  are  involved,  the 
seizures  may  assume  an  epileptiform  character.  Spasmodic  contractions 
often  occur  in  the  muscles  of  the  neck  and  back,  or  they  may  be  con- 
fined to  the  arm  and  leg  of  one  side.  Paralyses  then  develop.  They 
may  be  either  monoplegias  or  hemiplegias,  the  latter  depending,  as  a 
rule,  upon  involvement  of  the  cortical  branches  of  the  middle  cerebral 
artery  or  upon  softening  in  the  internal  capsule.  Facial  paralysis  is  the 
most  common  form  of  monoplegia.  It  is  sometimes  associated  with 
paralysis  of  the  extremities,  the  parts  supplied  by  the  third  nerve,  and 
the  hypoglossal  nerve  of  the  opposite  side.  This  association  of  paral- 
yses is  known  as  the  syndrome  of  Weber.  The  lesion  is  in  the  lower, 
inner  part  of  the  crus.  Optic  neuritis  may  also  be  found.  The  pupils 
again  become  contracted,  the  eyelids  remain  partially  open,  and  the 
globe  is  rolled  upward. 

Toward  the  close  of  the  disease  the  temperature  often  becomes  sub- 
normal; in  exceptional  cases  as  low  as  93°  or  94°  F.  (33.0° — 34-o°  C); 
occasionally,  however,  there  is,  shortly  before  death,  a  rapid  rise  to 
106°  or  even  110°  F.  (41.0^—43.0°  C).  The  pulse  becomes  rapid,  and 
the  child  sinks  into  a  typhoid  state  with  a  dry  tongue  and  low  delirium. 
Leucocytosis  is  not  infrequently  present  throughout  the  course  of  the 
disease.  The  duration  of  the  disease  is  from  two  or  three  to  four  weeks, 
seldom  longer. 

Diagnosis.— The  diagnosis  is  seldom  difficult  when  the  character  of 
the  invasion  and  the  distinctive  features  already  referred  to  are  fortified 
by  a  history  of  tuberculosis  in  the  family  or  the  presence  of  a  tuber- 
culous lesion  in  another  part.  But  in  young  infants  many  other  dis- 
turbances, as  a  gastroenteritis,  may  excite  rapidity  of  the  pulse  and 
respiration  or  convulsions.  The  train  of  symptoms  is,  however,  entirely 
different.  In  gastroenteritis,  diarrhea  is  present  and  the  fontanels  are 
depressed;  they  are  usually  prominent  in  meningitis.  The  hydrocephalic 
cry  and  irregularity  of  the  pulse  and  respiration  are  absent. 

Lobar  pneumonia  in  young  children  is  often  mistaken  for  meningitis, 
but  less  frequently,  perhaps,  for  the  tubercular  form  of  it.     In  it  the  onset 


1 82  PRACTICE  OF  MEDICINE 

is  more  sudden,  retraction  of  the  head,  constipation,  and  paralytic  mani- 
festations are  absent  or  much  less  prominent. 

Otitis  media,  accompanied  by  the  retention  of  pus,  may  cause  meningeal 
irritation  with  the  production  of  symptoms  suggestive  of  meningitis ;  the 
latter  condition  is  in  fact  sometimes  produced.  Puncture  of  the  drum 
membrane  and  evacuation  of  the  pus  quickly  establishes  the  diagnosis. 

Cerebrospi?ial  Meningitis. — From  this  disease  the  tubercular  form  is 
distinguished  by  the  less  sudden  onset  in  most  cases,  but  especially  by 
the  absence  of  the  diplococcus  intracellularis  in  the  fluid  obtained  by 
lumbar  puncture.  The  bacillus  tuberculosis  may  be  obtained  in  it.  In 
both  conditions  the  tension  of  the  fluid  is  increased,  but  the  withdrawal 
of  a  sterile  fluid  is  also  quite  characteristic  of  the  tubercular  form  of 
the  disease. 

Prognosis. — The  disease  is  almost  invariably  fatal.  Recovery  is  so 
improbable  that  in  the  few  cases  that  have  been  reported  the  diagnosis 
has  been  called  in  question.  Quite  recently,  however,  a  case  has  been 
observed  in  which  recovery  occurred  after  the  demonstration  of  the 
bacilli  tuberculosis  in  the  cerebrospinal  fluid.  Calomel  was  the  only 
therapeutic  agent  employed. 

Treatment. — It  is  considered  useless  to  attempt  more  than  the  relief 
of  suffering.  To  this  end  the  patient  should  be  placed  upon  a  soft 
bed  in  a  moderately  dark  room  and  he  should  be  disturbed  as  little  as 
possible.  For  the  relief  of  pain  and  restlessness  sodium  bromid,  gr. 
V  to  X  (0.3—0.6),  and  chloral,  gr.  ij  to  iij  (0.1—0.2),  may  be  given  to  a 
child;  but  if  this  fails,  and  especially  in  the  meningeal  form,  opium  in 
the  form  of  paregoric,  Dover's  powder,  codein,  or  morphin  should  be 
given  in  sufficient  doses  to  control  the  nervous  manifestations.  It  may 
become  necessary  to  administer  food  by  the  rectum  and  drugs  hypo- 
dermically  when  the  vomiting  is  uncontrollable  or  the  delirium  active. 
An  ice-cap  should  be  applied  to  the  head.  The  constipation  may  be 
relieved  by  enemata,  glycerin  suppositories,  repeated  doses  of  calomel, 
or  a  saline  laxative  of  which  the  effervescent  magnesium  citrate  is  gen- 
erally the  most  acceptable.  The  diet  should  consist  chiefly  of  milk  with 
broths  and  eggs. 

II.   LOCALIZED  TUBERCULOSIS. 

I.    TUBERCULOSIS  OF  THE  LYMPHATIC  SYSTEM. 
Tubercular  Adenitis,  Scrofula,  Tubercular  Lymphadenitis,  Scrofulosis. 

Etiology. — The  disease  is  much  more  common  between  the  first 
dentition  and  puberty  than  in  infancy  or  adult  life.  It  may  occur, 
however,  at  any  time  of  life.  The  bacilli  gain  entrance  through  the 
mucous  membrane  of  the  mouth,  throat,  bronchial  tubes,  or  intestine, 
possibly  sometimes  through  the  integument.  The  condition  is  therefore 
favored  by  a  catarrhal  condition  of  these  mucous  membranes,  and  more 
remotely  by  inherited  syphilis  or  a  tubercular  tendency,  both  of  which 
favor  the  development  of  catarrh.  Rachitic  children  are  also  readily 
infected.  In  adults  the  condition  may  follow  the  inhalation  of  dust.  It 
often  follows  an  attack  of  whooping-cough,  measles,  or  influenza. 


TUBERCULOSIS  183 

Morbid  Anatomy.— Tht  enlargement  of  the  afifected  glands  is  due 
chiefly  to  an  increase  in  the  number  of  their  lymphoid  cells.  These  cells 
also  appear  swollen  and  their  nuclei  are  large.  Miliary  tubercles,  some- 
times containing  giant  cells  and  bacilli,  are  also  found  in  the  glands. 
When  the  process  is  acute,  the  glands  occasionally  become  hyperemic; 
suppuration  is  unusual.  Later  the  tuberculous  tissue  may  undergo 
caseation  and  calcification.  When  suppuration  occurs  it  is  usually  with- 
out the  presence  of  pyogenic  organisms,  and  the  pus  is  sterile.  In  the 
neck  a  fistulous  opening  sometimes  forms  through  the  skin  for  the  evac- 
uation of  the  pus.  The  bronchial  glands  often  become  enormously 
enlarged.  Death  may  result  from  perforation  and  evacuation  of  their 
contents,  after  suppuration,  into  the  trachea  or  bronchi;  from  com- 
pression of  the  esophagus;  from  erosion  of  the  pulmonary  artery  or 
aorta  or,  more  remotely,  from  rupture  into  the  mediastinum  or  pleural 
cavity.  The  bronchial  glands  are  probably  the  most  frequent  source  of 
the  acute  dissemination  of  miliary  tubercles. 

Symptoms.  —  (i)  General  Adenitis. — This  form  is  characterized  by  a 
more  or  less  general  enlargement  of  all  the  lymph-glands  of  the  body. 
It  is  most  frequently  seen  in  the  negro  and  especially  in  connection  with 
pulmonary  tuberculosis.  The  condition  is  usually  accompanied  by  high 
fever  and  often  runs  a  rapidly  fatal  course.  It  frequently  resembles 
Hodgkin's  disease.  In  infants  and  children  a  general  adenitis  is  encoun- 
tered in  which  one  group  of  glands  is  involved  after  another,  ultimately 
terminating  in  a  fatal  invasion  of  the  meninges. 

(2)  Cervical  Adenitis. — This  form  is  the  most  common  in  children.  The 
swelling  involves  the  submaxillary  and  anterior  cervical  glands,  less  fre- 
quently the  posterior  cervical.  It  is  generally  unilateral  in  the  beginning, 
but  both  sides  are  not  infrequently  aff"ected.  The  individual  glands  are 
much  enlarged  and  firm.  In  size  they  vary  from  as  small  as  a  pea  to 
as  large  as  a  walnut.  They  are  not  usually  painful  or  sensitive  to 
pressure.  Large  masses  may  be  formed,  which  entirely  obliterate  the 
lines  of  the  neck.  It  was  probably  from  this  deformity  that  the  disease 
received  the  name  scrofula,  from  scrofa,  a  pig. 

Coryza  and  acute  nasopharyngeal  catarrh  are  common  accompani- 
ments of  the  adenitis  in  these  cases,  and  any  influence  which  aggravates 
the  catarrh  tends  to  increase  the  enlargement  of  the  glands.  Moderate 
fever  is  often  associated  with  the  acute  catarrhal  symptoms.  Slight 
inflammation  of  the  glands  may  occur  and  ultimately  pass  into  suppura- 
tion. Anemia  soon  appears  and  emaciation  follows  in  most  cases.  The 
general  condition  is  poor;  wounds  heal  slowly,  and  there  is  a  tendency 
to  conjunctivitis  or  keratitis,  otitis  and  eczema.  After  the  disease  has 
afifected  for  some  time  the  cervical  glands  there  is  frequently  an  involve- 
ment of  the  supraclavicular,  axillary,  and  bronchial,  and  this  extension 
of  the  disease  is  usually  followed  by  pulmonary  tuberculosis.  On  the 
other  hand,  the  condition  may  terminate  in  recovery  after  months  or 
years.  It  is  an  interesting  fact  that  persons  who  show  scars  of  early 
tubercular  adenitis  in  the  neck  are  seldom  the  victims  of  pulmonary 
tuberculosis  in  later  life. 

(3)  Tracheobronchial  Adenitis. — Enlargement  of  these  glands  ordinarily 
produces  cough,  dyspnea,  or  asthmatic  seizures.  Auscultation  sometimes 
reveals  the  evidence  of  compression  to  the  extent  of  a  roughened  inspir- 


1 84  PRACTICE  OF  MEDICINE 

atory  murmur  and  prolongation  of  expiration.  A  venous  purr  may 
sometimes  be  heard  by  auscultation  over  the  upper  portion  of  the  ster- 
num, with  the  head  of  the  patient  thrown  far  back.  Extreme  enlargement 
may  cause  compression  of  the  esophagus  with  more  or  less  complete 
interference  with  deglutition.  Traction  diverticula  have  also  been  attrib- 
uted to  this  cause.  Infection  of  the  pleura  or  lung  by  direct  extension 
of  the  infection  or  acute  miliary  tuberculosis,  as  a  result  of  the  rupture 
of  a  suppurating  gland,  is  liable  to  develop  at  any  time.  The  same 
results  are  sometimes  observed  without  perforation.  Bronchopneumonia 
is  a  common  sequel. 

(4)  Mesenteric  Adenitis. — This  form  of  tuberculous  adenitis  produces 
a  condition  often  spoken  of  as  tabes  mesenterica.  In  it  the  mesenteric 
and  retroperitoneal  glands  become  enlarged  and  indurated  and  often 
undergo  caseation,  less  frequently  calcification,  and  very  rarely  suppura- 
tion. The  condition  may  be  primary,  the  infection  occurring  from  the 
intestinal  mucous  membrane,  but  it  is  commonly  secondary  to  other 
tubercular  disease.  The  patient,  usually  a  child,  becomes  anemic  and 
rapidly  emaciates.  The  skin  is  dry  and  wrinkled  and  the  hair  falls  out. 
Periodic  fever  is  usually  observed  and  may  be  attributed  to  the  dis- 
ordered digestion,  which  is  a  prominent  feature.  Diarrhea,  with  large, 
watery,  fetid  stools,  is  usually  present,  and  the  abdomen  is  tympanitic. 
The  abdominal  walls  become  thin,  and  when  meteorism  is  not  present 
the  enlarged  glands  may  sometimes  be  felt  through  it.  The  peritoneum 
is  often  involved  in  these  cases.  Enlargement  of  the  mesenteric  glands 
is  a  frequent  result  also  of  pulmonary  tuberculosis. 

Diagnosis. — The  cervical  form  of  the  disease  is  rarel}-  difficult  of  rec- 
ognition. The  tuberculous  history,  chronic  enlargement,  and  tendency 
to  caseation  or  suppuration  leave  little  doubt  of  the  character  of  the 
adenitis.  The  condition  is  to  be  differentiated  from  syphihtic,  lymph- 
adenomatous,  leukemic,  and  malignant  adenitis. 

Syphilis. — The  glands  of  the  groin,  axilla,  and  epitrochlear  region  are 
the  more  usually  involved  in  this  disease.  Suppuration  rarely  occurs 
in  them,  and  the  administration  of  antisyphilitic  treatment  promptly 
reduces  the  swelling. 

Ly7nphadenoina  (^Hodgkin' s  Disease^. — The  glands  are  more  movable, 
even  less  sensitive,  and  do  not  suppurate  or  undergo  caseation.  It  is 
more  common  in  adult  males.  The  disease  affects  groups  of  glands;  it 
is  common  in  the  posterior  cervical,  but  rare  in  the  submaxillary  or 
anterior  cervical. 

Lezckemia. — The  glandular  enlargement  may  resemble  that  of  tuber- 
culosis, but  the  condition  is  recognizable  by  the  profound  anemia  and 
extreme  leucocytosis. 

Sarcoma. — The  enlargement  of  the  glands  is  much  more  rapid  and  the 
adjacent  tissues  are  soon  involved  in  the  disease. 

Carcinoma  attacks  the  glands  only  secondarily  and  those  nearest  the 
primary  growth. 

Treatment. — The  measures  recommended  for  the  treatment  of  general 
tuberculosis  should  be  carefully  followed,  giving  the  child  all  the  benefit  of 
fresh  air  and  good  diet.  Local  applications  are  seldom  of  benefit;  mas- 
sage is  often  harmful.  The  application  of  equal  parts  of  guaiacol  and 
glycerin  has  proved  of  apparent  benefit.    The  internal  administration 


TUBERCULOSIS  185 

of  sirup  of  the  iodid  of  iron  often  assists  in  reducing  the  swelUng.  Cod- 
liver  oil  is  especially  useful  in  children.  Careful  removal  of  the  glands 
has  been  performed  with  benefit,  but  it  has  undoubtedly  been  the  means 
of  disseminating  the  virus.  It  should  be  attempted  only  when  rapid 
increase  of  size  or  suppuration  threatens  to  produce  rupture  of  the 
glands. 

2.   TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES. 

(i)  General  Serous-membrane  Tuberculosis. 

This  form  of  the  disease  may  be  only  a  part  of  an  acute  miliary 
tuberculosis,  or  it  may  be  an  independent  form  of  tuberculous  infection, 
without  visceral  involvement.  The  serous  membranes  may  become  in- 
volved simultaneously  or,  as  is  more  generally  the  case,  in  rapid  suc- 
cession. ((3!)  The  disease  may  be  acute,  the  infection  being  derived 
from  the  bronchial  or  mediastinal  lymph-glands,  or  in  women  from  the 
Fallopian  tubes.  The  pleurae  and  peritoneum  are  generally  involved. 
(/;)  A  chronic  form  occurs  also  in  which  there  is  exudation  and  the  for- 
mation of  cheesy  masses  in  the  pleurge  and  peritoneum,  and  it  is  not 
infrequently  accompanied  with  inflammatory  and  suppurative  processes. 
In  extremely  chronic  cases  the  tubercles  become  hard  and  fibrous,  the 
membranes  become  much  thickened,  and  little  or  no  exudation  occurs. 
The  pericardium  may  be  implicated  in  either  of  these  forms  of  the  disease. 

(2)  Tuberculosis  of  the  Pleura. 

Eiiology. — Fully  one-third  of  all  cases  of  acute,  nontraumatic  pleu- 
risy are  of  tubercular  origin.  Some  authors  regard  all  such  cases  as 
of  this  character,  since  a  very  large  number  of  them  respond  to  the 
tuberculin  test  and  others  are  followed  by  pulmonary  tuberculosis  a  few 
months  or  possibly  several  years  afterward.  But  on  the  other  hand 
there  can  be  no  doubt  that  many  acute  cases  entirely  recover.  The 
condition  may  be  :  (a)  Primary  and  independent  of  other  tuberculous 
infection;  (^)  a  part  of  an  acute  mihary  tuberculosis;  (r)  secondary 
to  the  ordinary  form  of  pulmonary  tuberculosis,  or  to  a  tubercular  proc- 
ess in  the  cervical  or  bronchial  glands,  or  the  bodies  of  the  vertebrae; 
or  (^/)  it  may  be  a  part  of  a  general  involvement  of  the  serous  mem- 
branes. Probably  not  all  instances  of  the  development  of  pleuritic 
inflammation  in  the  course  of  chronic  pulmonary  tuberculosis  are  of  a 
tuberculous  nature,  however,  for  they  frequently  leave  only  fibrous  adhe- 
sions between  the  two  layers,  without  discoverable  tubercle-formation. 

Symptoms. — The  infection  is  generally  unilateral  and  it  may  pursue 
an  acute,  subacute,  or  chronic  course.  Such  prodromal  symptoms  as 
cough,  mucopurulent  expectoration,  anemia,  emaciation,  sometimes  an 
occasional  hemoptysis,  may  precede  either  of  the  forms  for  many  months, 
especially  when  the  disease  occurs  in  the  course  of  chronic  pulmonary 
tuberculosis. 

Acute  Form. — The  actual  onset  of  the  pleuritic  involvement  is  often 
announced  by  the  occurrence  of  a  sharp  stitch  in  the  side  or  by  a  dis- 
tinct chill.  An  exudate  quickly  forms  in  most  cases,  and,  partly  at  least 
as  a  result  of  it,  there  are  cough,  dyspnea,  and  moderate  elevation  of 


1 86  PRACTICE  OF  MEDICINE 

temperature,  usually  from  ioi°  to  103°  F.  (38.5° — 39.5°  C).  The  ex- 
udate may  be  serous  or  serofibrinous  in  the  beginning,  but  frequently 
becomes  seropurulent,  sanguinolent,  or  purulent  as  the  disease  progresses. 
A  purulent  change  is  invariably  induced  by  tapping  without  proper 
antiseptic  precautions.  The  most  characteristic  fluid  is  slightly  green- 
ish, opalescent,  seropurulent,  and  contains  granular  fat  and  a  few  leu- 
cocytes. Tubercle  bacilli  and  other  bacteria  may  be  present,  or  the 
fluid  may  be  sterile.  In  many  cases,  after  a  course  of  from  three  to  six 
weeks,  the  fever  and  pain  subside  and  the  exudate  is  gradually  absorbed. 
In  other  cases  the  disease  becomes  chronic. 

The  subacute  and  chronic  fot'ms  may  follow  the  acute  or  they  may 
develop  so  insidiously  as  to  appear  chronic  from  the  first.  After  a  long 
period  of  cough,  emaciation,  and  loss  of  weight  and  strength,  slight 
pleuritic  pain  may  be  complained  of,  or  physical  examination  may  first 
reveal  impaired  expansion  of  the  affected  side  of  the  chest,  with  an 
accumulation  of  fluid  in  the  pleural  cavity,  or  dullness  due  to  thickening 
of  the  pleura.  The  fluid  may  be  serofibrinous  or  purulent.  The  thick- 
ening of  the  pleura  varies  from  ^^  to  i  inch  (0.5 — 2.5  cm.)  and  there 
is  sometimes  only  a  small  quantity  of  a  thick  caseous  fluid  at  the  base 
of  the  cavity.  The  pleural  cavity  may,  indeed,  be  almost  completely 
obliterated  through  hyperplasia  of  the  membrane  and  the  formation 
of  adhesions  between  the  parietal  and  visceral  layers.  A  most  virulent 
type  of  empyema  or  pyopneumothorax  is  developed  in  these  cases 
by  the  rupture  of  an  abscess  cavity  or  a  softened  caseous  nodule  in  the 
lung.  In  the  less  fatal  cases  of  primary  tuberculosis  of  the  pleura  the 
lung  may  ultimately  become  involved  or  an  acute  miliary  tuberculosis 
may  be  instituted. 

Diagnosis. — The  diagnosis  of  pleurisy  is  considered  under  the  diseases 
of  the  pleura.  The  tuberculous  character  of  the  condition  is  sometimes 
determined  with  much  difficulty  if  the  disease  be  primary,  but  in  the 
presence  of  pulmonary  or  other  recognized  tuberculous  infection  there  is 
always  a  strong  probability  of  its  tubercular  nature.  The  presence  of 
blood  or  tubercle  bacilli  in  the  exudate  or  the  discovery  of  bacilli  in  the 
sputum  is  highly  confirmatory  of  the  diagnosis.  When  no  other  means 
is  sufficient  for  the  determination  of  the  condition,  the  successful  inocu- 
lation of  a  guinea-pig  with  the  aspirated  fluid  will  establish  the  diag- 
nosis. 

Treatment. — This  combines  the  general  methods  of  treating  tuber- 
culosis and  those  for  the  relief  of  pleurisy. 

(3)  Tuberculosis  of  the  Pericardium. 

Etiology. — The  pericardium  is  much  less  frequently  affected  than  the 
other  serous  membranes.  It  is  usually  secondary  to  disease  in  other 
parts,  perhaps  never  primary  in  character.  It  may  be  a  part  of  a 
miliary  tuberculosis  or  it  may  result  from  tuberculosis  of  the  mediastinal 
or  bronchial  glands,  or  it  may  be  a  direct  extension  from  disease  in 
the  pleura  or  lung.  Either  layer  of  the  pericardium  may  be  involved 
and  the  disease  may  be  either  acute  or  chronic,  simple  or  purulent. 
The  quantity  of  the  exudate  varies  from  a  little  more  than  normal 
to  as  much  as  64  ounces   (Musser).      The  disease  is  sometimes  latent 


TUBERCULOSIS  187 

and  may  be  discovered  only  at  autopsy.  As  in  tuberculous  pleurisy, 
the  membrane  may  be  greatly  thickened  and  the  layers  of  the  pericar- 
dium may  become  more  or  less  completely  adherent.  As  a  result  of 
the  latter  condition  hypertrophy  and  dilatation  of  the  heart  are  pro- 
duced, and  valvular  insufficiency  often  results  from  this  change.  A  loud, 
blowing  systolic  bruit  is  often  heard  at  the  apex,  corresponding  in  time 
to  that  of  either  a  stenosis  or  an  insufficiency. 

Treatment — The  treatment  consists  in  the  application  of  the  meas- 
ures employed  in  a  nontuberculous  pericarditis  and  those  for  the  general 
treatment  of  tuberculosis. 

(4)  Tuberculosis  of  the  Peritoneum. 

Eiiology. — The  condition  is  probably  never  primary  in  its  origin. 
It  may  be  secondary  to  tuberculous  disease  of  the  endometrium  or 
Fallopian  tubes,  the  intestine,  or  mesentery.  It  has  also  been  traced 
to  disease  of  the  epididymis,  the  vesiculge  seminales,  or  prostate.  It 
may  be  a  part  of  a  miliary  tuberculosis,  the  bacilli  reaching  the  peri- 
toneum through  the  blood;  or  of  a  general  tuberculosis  of  the  serous 
membranes.  It  may  result  from  the  perforation  of  a  tuberculous  focus 
that  has  undergone  softening  or  suppuration  in  any  of  the  adjacent 
organs.  Trauma  of  the  abdomen  is  thought  to  have  an  influence  in 
producing  localization  of  the  infection  in  the  peritoneum.  Cirrhosis 
of  the  liver  and  hernia  are  thought  to  favor  its  development.  The 
disease  may  occur  at  any  age,  but  is  especially  frequent  in  children, 
when  it  is  usually  a  result  of  the  extension  of  infection  from  the  intestine 
or  mesentery.  Its  occurrence  in  the  two  sexes  is  probably  about  equal, 
since  it  has  been  noted  more  frequently  by  the  gynecologist  than  by 
the  surgeon;  but  in  men  it  is  oftener  found  on  the  post-mortem  table. 

Morbid  Anatomy. — The  tubercles  are  usually  numerous,  studding  the 
entire  surface  of  the  peritoneum;  more  rarely  they  are  confined  to 
a  circumscribed  area.  The  character  and  the  quantity  of  the  exudate 
vary  considerably,  and  the  other  conditions  correspond  to  these  features. 
When  the  disease  is  a  part  of  an  acute  tuberculosis,  the  peritoneum 
is  studded  with  young,  gray,  translucent  tubercles,  smaller  than  pin- 
heads.  In  a  less  acute  form  the  tubercles  show  a  tendency  to  become 
clustered  into  patches  or  nodular  masses,  and  the  peritoneum  is  often 
much  thickened.  It  is  also  hyperemic  in  many  cases,  and  covered  with 
a  layer  of  fibrin.  The  subsequent  changes  may  be  of  a  caseous,  sup- 
purative, ulcerative,  or  sclerotic  character,  with  the  production  of  a 
variety  of  lesions.  The  tubercles  are  often  opaque,  yellowish,  and  ca- 
seous, and  the  larger  masses  that«are  formed  may  undergo  caseation 
or  suppuration.  The  omentum  is  especially  prone  to  involvement  and 
often  becomes  shrunken  into  a  dense  roll.  The  mesentery  also  becomes 
greatly  thickened  by  a  fibrous  increase  and  may  draw  the  attached 
intestine  into  a  firm,  tumor-like  mass.  The  tissues  are  frequently  much 
indurated  and  pigmented.  The  skin  also  shows  pigmentation  in  many 
of  the  more  chronic  cases.  The  exudate  is  generally  abundant  in  the 
acute  form,  but  it  may  be  much  or  little  in  the  chronic.  In  character 
it  may  be  either  serous,  fibrinoserous,  or  hemorrhagic;  it  is  not  often 
purulent.    The  adhesions  are  numerous  in  chronic  cases.     They  some- 


1 88  PRACTICE  OF  MEDICINE 

times  campletely  encapsulate  the  exudate,  forming  several  isolated  sacs. 
The  tubercles  may  be  concealed  between  the  adherent  surfaces.  Large 
masses  are  sometimes  formed  which  are  readily  mistaken  on  palpation 
for  cancerous  formations.  The  wall  of  the  intestine  is  sometimes  per- 
forated within  these  circumscribed  areas. 

A  localized  tubercular  peritonitis  sometimes  occurs,  producing  large 
caseous,  often  pigmented  masses  on  the  surfaces  corresponding  to  the 
localization  of  tuberculous  ulcers  wdthin  the  bowel,  or  to  similar  tuber- 
culous formations  in  the  Fallopian  tubes ;  hkewise  on  the  inferior  surface 
of  the  diaphragm  when  the  pleura  or  pericardium  is  affected. 

Symptoms. — The  condition  may  be  either  acute  or  chronic :  («-) 
Acute  Tubercular  Peritonitis. — In  the  very  acute  cases  the  onset  may 
be  sudden  and  violent,  with  intense  pain,  great  tenderness,  meteorism, 
and  vomiting.  Constipation  is  usually  present,  unless  diarrhea  is  pro- 
duced by  the  simultaneous  presence  of  tubercular  enteritis.  These 
cases  resemble  acute  enteritis,  appendicitis,  hernial  strangulation,  the 
perforation  of  a  typhoid  ulcer,  or  acute  obstruction. 

The  course  of  the  disease  may  be  intermittent,  attacks  of  severe 
pain  alternating  with  intervals  of  almost  complete  relief.  Fever  is 
usually  present,  often  reaching  103°  or  104°  F.  (39-5°  or  40.0°  C). 
With  the  formation  of  the  exudate,  the  abdomen  becomes  more  distended 
and  the  presence  of  fluid  may  be  recognized  by  dullness  and  fluctuation. 
The  other  symptoms  of  acute  general  peritonitis — rapid  pulse,  distended, 
motionless  abdomen,  dorsal  decubitus,  elevated  knees,  and  anxious, 
Hippocratic  facies — are  generally  noted  in  acute  cases. 

In  less  acute  cases  the  symptoms  develop  slowly  and  the  pain  is 
less  severe.  There  may  be  a  gradual  rise  of  temperature,  possibly  to 
103°  F.  (39.5°  C),  and  the  cKnical  picture  may  be  that  of  typhoid 
fever.  In  some  instances  the  disease  remains  for  a  long  time  latent 
until  the  ascites  causes  it  to  be  recognized.  The  exudate  may  become 
so  abundant  as  to  interfere  with  respiration  and  cause  embarrassment 
of  the  portal  and  renal  circulation.  Subacute  cases  are  particularly 
liable  to  pass  into  the  chronic  form. 

(JT)  Chronic  Tubercular  Pei'itonitis. — This  form  corresponds  to  the 
caseous,  suppurative,  and  sclerotic  conditions  referred  to  under  Morbid 
Anatomy.  The  abdomen  often  becomes  firm  and  indurated.  The 
shrunken  omentum  and  intestine  may  often  be  felt  through  the  abdom- 
inal wall  as  large,  tumor-like  masses.  The  fever  is  usually  slight,  or  it 
may  be  absent;  a  subnormal  temperature  is  not  uncommon,  the  oscilla- 
tion often  being  confined  for  days  between  95.5°  and  97°  F.  (35.2°  and 
36.2°  C).  WTien,  however,  suppuration  occurs,  the  temperature  rises 
and  pursues  an  irregular  course.  With*  the  progress  of  the  disease, 
anemia  and  emaciation  become  more  and  more  pronounced,  with  cor- 
responding loss  of  strength  and  reduction  of  weight.  More  or  less  com- 
plete occlusion  of  the  bowel  may  develop  at  anj-  time  or  the  intestinal 
wall  may  become  tubercular  and  diarrhea  often  sets  in  with  bloody 
dejections.  Intestinal  perforation  may  take  place  and  cause  a  sudden, 
violent  exacerbation  of  the  symptoms.  Leucocytosis  is  generally  absent 
in  all  forms  of  tubercular  peritonitis. 

Diagnosis. — The  condition,  especially  when  discovered  at  operation, 
is  to  be  distinguished  first  from  the  non-tuberculous  nodular  grown:hs 


TUBERCULOSIS  189 

that  are  occasionally  found  upon  the  peritoneum.  The  differentiation 
can  be  made  in  many  instances  only  by  the  demonstration  of  the 
bacillus  tuberculosis  or  the  tuberculin  test.  The  condition  is  perhaps 
often  mistaken  for  tubercular  peritonitis.  In  the  acute  cases  the  dif- 
ferentiation is  usually  to  be  made  from  typhoid  fever,  appendicitis, 
strangulated  internal  hernia,  and  intestinal  obstruction ;  and  in  chronic 
cases  from  ovarian  cyst  and  other  abdominal  tumors  with  fluid  con- 
tents, as  well  as  from  chronic  peritonitis  of  nontuberculous  nature  just 
referred  to. 

Typhoid  Fever. — This  is  excluded  by  the  absence  of  epistaxis,  enlarge- 
ment of  the  spleen,  or  roseola,  and  the  negative  reaction  of  the  Widal 
test. 

Appendicitis. — In  this  disease  the  abdominal  distention  is  more  uni- 
lateral, the  right  rectus  is  tense,  the  right  knee  alone  elevated;  and  the 
presence  of  a  sausage-like  tumor  in  the  ileac  fossa,  with  tenderness  at 
McBurney's  point,  is  distinctive.     Leucocytosis  is  usually  present. 

Hernial  Strangiilatio7i. — This  condition  or  obstruction  from  any  other 
cause  develops  suddenly;  the  patient  may  be  free  from  suspicion  of 
tubercular  disease.  The  pain  is  localized  and  paroxysmal;  tympanites 
is  marked.  The  most  valuable  symptom  is  feculent  vomiting,  which 
generally  sets  in  within  a  few  hours. 

Acute  Enteritis. — This  is  liable  to  cause  confusion  only  when  it  occurs 
in  a  tuberculous  subject.  The  profuse  diarrhea  tends  to  reduce  rather 
than  to  increase  the  abdominal  distention,  and  there  is  seldom  marked 
elevation  of  temperature  or  the  typhoid  state. 

Abdominal  Tumors. — The  differentiation  of  these  growths,  of  whatever 
kind,  is  to  be  made  chiefly  by  a  study  of  the  etiology.  In  the  presence 
of  an  evident  source  of  tubercular  infection,  in  the  lung,  genitourinary 
tract,  or  elsewhere,  the  condition  is  most  likely  to  prove  tubercular. 
Ovarian  cyst  is  generally  slower  in  growth,  -and  malignant  neoplasms 
more  rapid,  than  tuberculous  nodules.  Febrile  attacks  and  digestive  dis- 
turbances are  less  frequently  observed  in  connection  with  them. 

Prognosis. — The  chance  of  permanent  recovery  is  exceedingly  poor. 
Spontaneous  recovery  sometimes  occurs  in  cases  regarded  as  tuberculous, 
and  laparotomy  frequently  gives  relief.  Cures  have  been  claimed  from 
it  in«from  70  to  80  per  cent  of  cases,  but  relapse  is  the  rule  in  cases 
of  known  tuberculous  character,  sometimes  after  months  or  years  of 
apparent  freedom  from  the  disease. 

Treatment — The  treatment  is  constitutional,  symptomatic,  and  sur- 
gical. The  former  embraces  the  methods  for  general  tuberculosis.  Rest 
is  essential.  The  food  should  be  the  most  nourishing  and  as  largely 
as  possible  of  meat.  Pain  may  be  relieved  by  hot  fomentations,  poul- 
tices, ice-bags,  the  application  of  iodin  or  turpentine  stupes ;  but  opiates 
may  be  required.  Constipation  calls  for  laxatives;  excessive  diarrhea, 
for  opiates  and  astringents.  Guaiacol,  iodoform,  and  salol  may  be  used 
as  intestinal  antiseptics,  and  they  possibly  exert  an  influence  on  the 
disease.  Withdrawal  of  the  fluid  by  repeated  aspiration  under  strict 
asepsis  has  proved  efficient  in  some  cases,  but  laparotomy  is  generally 
resorted  to  when  other  methods  fail.  In  children  the  administration  of 
sirup  of  the  iodid  of  iron  and  the  application  of  guaiacol  in  glycerin 
to  the  abdomen  have  sometimes  proved  beneficial. 


I90  PRACTICE  OF  MEDICINE 

3.    TUBERCULOSIS  OF  THE  RESPIRATORY  ORGANS. 

(i)  Tuberculosis  of  the  Nose. 

The  nasal  cavities  are  rarely  the  seat  of  tuberculosis.  It  is  not  infre- 
quent, however,  to  find  the  bacilli  within  the  nostrils  of  healthy  indi- 
viduals, and  this  fact  probably  indicates  that  this  mucous  membrane  is 
less  susceptible  to  infection  than  that  of  the  lower  respiratory  passages. 
WTien  the  disease  occurs,  it  is  usually  secondary  to  tuberculosis  elsewhere. 

Symptoms. — The  condition  is  one  of  catarrh,  with  more  than  the  ordi- 
nary tendency  to  hyperplasia  of  tissue  and  the  formation  of  ulcers.  These 
in  turn  lead  to  the  formation  of  large  crusts  and  frequent  epistaxis, 
especially  upon  removal  of  the  accumulations. 

The  condition  is  usually  a  part  of  a  late  tuberculosis  and  not,  there- 
fore, of  long  duration.  The  treatment  consists  of  the  removal  or  de- 
struction of  the  nodes  and  ulcers,  but  as  the  disease  is  attended  with 
little  or  no  pain  the  adoption  of  painful  measures  can  hardly  be  advised. 

(2)  Tuberculosis  of  the  Larynx. 

Etiology. — The  disease  is  rarely  primary  in  character,  and,  when  it 
is  so,  it  probably  originates  from  inoculation  with  bacilli  in  the  inspired 
air.  As  a  secondary  infection  it  is  not  uncommon,  especially  as  a  late 
complication  of  pulmonary  tuberculosis.  The  infection  may  originate 
from  the  sputum  which  passes  over  the  larynx  from  the  lungs  or  it 
may  be  conveyed  through  the  blood-vessels  or  lymphatics.  A  lesion 
is  necessary  to  permit  the  entrance  of  the  bacilli,  and  such  a  lesion 
may  no  doubt  be  produced  by  violent  coughing. 

Morbid  Anatomy. — The  mucous  membrane  becomes  swollen,  partic- 
ularly over  the  arytenoid  cartilages,  and  tubercles  form  in  it,  at  first 
in  the  vicinity  of  the  blood-vessels.  Hyperemia  does  not,  however,  ap*- 
pear  until  comparatively  late.  The  tubercles  group  themselves  into 
a  few  small  nodules,  as  a  rule,  then  undergo  caseation  and  break  down, 
leaving  shallow  ulcers  of  unequal  size  and  irregular  shape.  These  are  situ- 
ated, in  most  cases,  over  the  arytenoid  cartilages,  on  the  vocal  cords, 
and  on  the  epiglottis.  The  adjacent  mucous  membrane  becomes  thick- 
ened, especially  over  the  arytenoids.  Later  the  ulceration  may  lead 
to  the  total  destruction  of  the  vocal  cords  and  epiglottis  and  the 
development  of  perichondritis,  sometimes  with  exfoliation  of  cartilage. 
The  disease  shows  a  tendency  to  spread  in  all  directions.  It  may  extend 
laterally  and  upward  to  involve  the  fauces,  pharynx,  and  tonsils,  or 
downward  over  the  cricoid  cartilages.  Stenosis  of  the  larynx  is  one 
of  its  infrequent  results,  being  produced  by  the  contraction  of  cicatricial 
tissue  following  the  ulceration. 

Symptoms. — The  involvement  of  the  larynx  is  usually  announced 
by  a  huskiness  of  the  voice  that  increases  to  a  decided  hoarseness  and 
in  extreme  cases  to  complete  aphonia.  Deglutition  and  phonation  be- 
come difficult  and  painful.  The  cough  is  at  first  not  very  severe, 
but  later,  when  ulceration  has  occurred,  it  becomes  extremely  trouble- 
some, hoarse,  and  ineffectual,  often  paroxysmal.  Dyspnea  is  a  frequent 
accompaniment  of  the  condition,     \\Tien  the  epiglottis  becomes  exten- 


TUBERCULOSIS  191 

sively  ulcerated,  swallowing  is  correspondingly  difficult.  Food  often 
enters  the  larynx  and  causes  paroxysms  of  coughing  and  threatened 
suffocation.  Laryngoscopic  examination  reveals  a  characteristic  thicken- 
ing and  pallor  of  the  mucous  membrane,  or,  later,  an  extensive  destruc- 
tion of  tissues.  The  ulcers  are  shallow,  have  an  irregular  outline,  and- 
the  base  is  usually  covered  with  a  gray,  necrotic  exudate.  The  vocal 
cords  are  thickened,  usually  ulcerated. 

Diagnosis. — The  disease  is  to  be  distinguished  chiefly  from  catarrhal 
and  syphilitic  laryngitis.  Catarrhal  laryngitis  may  occur  in  a  tubercu- 
lous patient.  The  differentiation  is  often  difffcult,  since  the  presence  of 
bacilli  may  be  only  accidental.  Ulceration  is  seldom  so  extensive,  and 
the  peculiar  pallor  is  not  usually  present.  From  the  syphilitic  form  the 
tubercular  is  to  be  differentiated  chiefly  by  the  history  of  the  case,  the 
presence  of  tubercle  bacilli,  and  the  absence  of  general  glandular  enlarge- 
ment. 

Prognosis. — The  prospect  for  cure  is  not  only  bad  in  all  cases,  but 
the  development  of  laryngeal  tuberculosis  in  the  course  of  the  pulmonary 
disease  adds  an  element  of  great  gravity  to  the  case. 

Treatment. — The  general  treatment  is  that  of  the  underlying  pul- 
monary tuberculosis;  nothing  is  so  important  as  fresh  air  and  light,  with 
tonics  and  nutritious  food. 

Local  Treatment. — The  ulcers  should  be  kept  clean  with  an  alkaline 
spray.  Astringents  may  be  applied  in  the  same  manner.  A  solution 
of  menthol  and  camphor  gives  great  relief.  Creosot  should  sometimes 
be  added  to  the  solution.  In  advanced  cases  cocain  may  be  required, 
particularly  at  mealtime,  to  prevent  the  pain  of  swallowing.  Insuffla- 
tion of  iodoform  after  thorough  cleansing  is  thought  to  promote  heal- 
ing. Extensive  ulceration  requires  the  care  of  a  specialist  who  may  be 
able  to  improve  the  condition  by  curetting  and  applying  caustics,  silver 
nitrate  or  lactic  acid.  After  destruction  of  the  epiglottis  the  patient 
is  able  to  take  nourishment  only  in  fluid  form,  sometimes  by  sucking 
it  through  a  tube  with  the  face  downward,  but  generally  only  through 
the  stomach-tube. 

(3)  Tuberculosis  of  the  Lungs. 

Pulmonary  Tuberculosis,  Phthisis  Pulmonum,  Consumption. 

Infection  of  the  lungs  arises  most  frequently  from  the  inhalation  of 
bacilli-laden  dust;  less  frequently  through  the  blood-  or  lymph-vessels. 
The  conditions  developed  are  not  identical.  When  the  bacilli  have 
entered  through  the  bronchial  tubes,  the  primary  lesions  are  usually 
found  in  the  smaller  bronchi  and  bronchioles.  Their  walls  become  in- 
filtrated with  granulation  cells  and  surrounded  by  layers  of  lymphoid 
and  epithelioid  cells  forming  peribronchial  granulations  which  are  often 
found  in  a  state  of  caseation.  The  lumen  of  the  tubes  becomes  closed 
by  a  caseous  mass  of  desquamated  epithelium.  The  condition  is  not 
confined  to  single  groups  of  alveoli,  but  affects  more  distinctly  lobules, 
sometimes  even  an  entire  lobe. 

When  the  bacilli  reach  the  lungs  through  the  blood  or  lymph,  the 
primary  lesions  are  located  in  the  walls  of  the  alveoli,  capillary  vessels, 
or  the  connective  tissue  of  the  interalveolar  septa.      Tubercles  of  the 


192  PRACTICE  OF  MEDICINE 

miliary  type,  small,  microscopic  collections  of  cells,  are  formed  within 
a  few  days,  but  soon  coalesce  to  form  larger  masses.  The  subsequent 
changes  in  them  are  the  same  as  have  been  previously  described  under 
the  head  of  Morbid  Anatomy  of  Tubercle,  on  page  175.  The  condition 
may  be  either  localized  or  general  throughout  the  lungs.  When  the 
disease  is  a  part  of  a  general  tuberculous  infection,  the  tubercles  are 
found  in  all  parts  of  both  lungs.  When  the  process  is  localized,  it  is 
generally  confined  to  the  apex  of  one  lung;  a  little  more  frequently 
(about  as  7  to  5)  in  the  left;  next  most  frequently  in  one  lower  lobe, 
near  the  base  or  in  the  middle  portion,  as  a  rule.  From  the  area 
originally  involved  the  disease  gradually  extends  until  it  invades  the 
greater  part  of  both  lungs.  The  mode  of  extension  is  either  :  (^) 
Directly  to  contiguous  tissue,  through  which  numerous  foci  are  frequently 
merged;  (^i^}  by  transmission  through  the  blood-vessels  or  lymph- 
channels  to  more  distant  parts  of  the  lungs ;  or  (^)  by  the  inoculation 
of  other  parts  from  the  sputum  in  its  passage  outward  or  through  its 
aspiration  into  adjacent  lobules. 

There  are  three  principal  forms  Of  pulmonary  tuberculosis,  the  acute 
pneumonic,  the  chronic  ulcerative,  and  the  fibroid. 

(/)  Acute  Pneumonic   Tuberculosis. 

Pneumonic   Phthisis,   Caseous  Pneumonia,  Phthisis  Florida,  Galloping  Con- 
sumption. 

Of  this  disease  there  are  two  forms,  the  pneumonic  and  the  bron- 
chopneumonic,  distinguishable  clinically  and  by  their  pathological  lesions. 

(a)  The  Pneumonic  TyJ>e.—Th.t  process  may  be  confined  to  a  single 
small  area,  perhaps  to  oiie  apex,  but  it  may  involve  an  entire  lung. 
It  is  usually  rapid  in  its  progress.  The  affected  area  becomes  solidified, 
heavy,  and  airless,  much  as  in  lobar  pneumonia.  The  sohdification 
is  due  to  the  infiltration  of  the  alveolar  septa  with  serum  and  leucocytes 
and  the  filling  of  the  air-cells  with  an  exudate  consisting  chiefly  of  pro- 
liferated and  desquamated  epitheHal  cells.  The  entire  area  subsequently 
undergoes  caseation,  and  small  cavities  are  formed,  except  in  the  more 
rapid  fatal  cases.  The  infiltrated  area  may  appear  so  nearly  homo- 
geneous on  post-mortem  examination  as  to  render  the  recognition  of 
the  tubercles  quite  impossible  without  the  microscope.  As  a  rule,  how- 
ever, the  character  of  the  lesions  will  be  revealed  by  the  finding  of  the 
more  chronic  changes  in  other  parts  of  the  lungs.  The  bronchial  glands 
are  always  enlarged,  and  the  pleura  over  the  affected  areas  is  covered 
with  fibrin  or  caseous  matter.  The  surrounding  portions  of  the  lungs 
may  be  hyperemic,  but  there  is  never  any  evidence  of  a  tendency  to 
resolution. 

Symptoms. — The  disease  may  develop  insidiously  in  a  person  who  has 
been  debilitated  by  illness,  alcohohsm,  or  overwork  and  exposure,  or 
it  may  be  announced  by  a  chill.  It  sometimes  occurs  in  individuals 
in  apparently  good  health.  A  severe  cough  develops,  the  sputum  be- 
comes mucopurulent,  sometimes  "rusty,"  and  often  contains  bacilli 
and  later  elastic  tissue  from  the  disintegrating  lung.  The  temperature 
rapidly  rises,  perhaps  to  103°  or  104°  F.  (39.5°— 40°  C).    There  is  pain 


TUBERCULOSIS  '      '  193 

in  the  side.  Sweating  usually  occurs  at  frequent  intervals,  especially 
at  night.  The  pulse  is  accelerated,  the  breathing  becomes  rapid,  a.nd 
dyspnea  may  become  urgent.  Physical  examination  reveals  consolida- 
tion, indicated  by  dullness,  increased  fremitus,  absence  of  vesicular  mur- 
mur and  tubular  breathing.  The  urine  may  show  the  diazo  reaction. 
The  condition  is  almost  identical  with  that  of  lobar  pneumonia,  but 
the  crisis  does  not  occur  and  the  condition  becomes  progressively  worse. 
The  rusty  sputum  becomes  changed  into  the  "prune-juice"  expectora- 
tion, the  prostration  becomes  extreme,  the  feet  become  edematous,  and 
cyanosis  may  develop.  Death  sometimes  occurs  as  early  as  the  second 
or  third  week,  but  it  may  be  delayed  as  long  as  two  or  three  months. 
Occasionally  the  acute  symptoms  subside  and  the  case  progresses  as 
one  of  chronic  tuberculosis. 

Diagnosis. — When  the  disease  occurs  in  one  who  has  not  previously 
been  the  subject  of  recognized  tuberculosis,  the  differentiation  from  lobar 
pneumonia  may  be  for  a  time  impossible.  The  condition  may  not  be 
suspected,  in  fact,  until  the  disease  is  found  to  be  growing  worse  instead 
of  undergoing  resolution  after  the  period  of  the  expected  crisis  has 
passed.  By  this  time,  however,  it  may  be  possible  to  demonstrate  the 
bacilli  in  the  sputum.  The  occurrence  of  repeated  chills  or  frequent 
chilly  sensations,  and  more  particularly  the  character  of  the  tempera- 
ture curve,  may  arouse  suspicion,  for  the  oscillations  are  usually  greater 
than  in  lobar  pneumonia,  often  amounting  to  2°  F.  (1.1°   C). 

(Ji)  BroncJiopneu7nonic  Type. — This  form  of  the  disease  is  more  com- 
mon than  the  pneumonic,  and  is  met  with  especially  as  a  sequel  to 
the  bronchitis  of  measles,  whooping-cough,  diphtheria,  or  other  acute 
infection  in  children  who  are  predisposed  to  tuberculosis.  Not  infre- 
quently, indeed,  the  disease  is  the  rekindling  of  a  tubercular  process 
already  existing  in  the  individual.  The  process  begins  in  the  smaller 
bronchi,  which  become  filled  with  a  cheesy  accumulation  of  desquamated 
epithelium.  As  a  result,  the  alveoli  are  closed,  and  a  catarrhal  pneu- 
monia is  virtually  established.  In  the  beginning  the  affected  areas  are 
hyperemic,  but  later  they  become  opaque  and  caseous.  The  consolidation 
is  usually  confined  to  more  or  less  isolated  areas  between  which  the  lung 
still  contains  air,  but  in  extreme  cases  an  entire  lobe  may  become  al- 
most solidified.  The  bronchial  glands  are  usually  much  enlarged.  In 
another  class  of  cases  the  affected  areas  are  small  and  confined  to 
different  parts  of  both  lungs,  generally  to  the  apices.  A  similar  condi- 
tion sometimes  results  from  the  aspiration  of  blood  and  the  contents  or 
tubercular  cavities  into  the  unaffected  portions  of  the  lungs  during  a 
hemoptysis.  Mixed  infection  sometimes  occurs  when  other  organisms 
gain  entrance,  but  in  many  cases  the  bacillus  tuberculosis  alone  is 
found. 

Symptoms. — In  children  the  disease  frequently  engrafts  itself  upon  a 
bronchial  catarrh  without  for  a  time  exciting  unusual  symptoms  further 
than  a  prolongation  of  the  condition.  On  close  observation,  however, 
the  child  will  be  found  to  have  a  fever,  with  flushed  cheeks  toward 
evening  (hectic  fever).  The  breathing  becomes  more  rapid  and  the 
expectoration  more  abundant.  Emaciation  also  develops  with  much 
rapidity.  On  physical  examination  slight  dullness  may  be  detected  at 
one  or  both  apices,  occasionally  in  other  parts  of  the  lungs. 

13 


194  PRACTICE  OF  MEDICINE 

In  other  cases  the  onset  is  more  abrupt.  The  child  may  be  in  an 
enfeebled  condition  from  previous  illness  or  it  may  be  the  subject  of 
rickets  or  of  unrecognized  tuberculosis.  There  is  a  sudden  rise  of  tem- 
perature and  severe  cough,  with  rapid  solidification  of  one  or  both 
apices,  and  numerous  subcrepitant  rales  are  heard  on  auscultation.  These 
cases  sometimes  terminate  fatally  within  three  or  four  days,  and  with- 
out microscopic  examination  of  the  lesions  there  may  be  nothing  to 
indicate  the  tubercular  character  of  the  bronchopneumonia. 

In  adults  the  disease  may  attack  an  individual  in  good  health,  but 
it  is  much  more  frequently  observed  in  those  who  have  been  debilitated 
or  those  who  are  the  subjects  of  tuberculosis.  The  attack  generally 
begins  with  a  succession  of  chills  or  chilly  sensations,  followed  by  high 
fever,  rapid  pulse  and  respiration.  Sometimes  there  is  hemoptysis. 
Emaciation  and  loss  of  strength  and  weight  rapidly  follow.  The  physi- 
cal signs  in  the  early  stage  of  the  disease  are  only  those  of  broncho- 
pneumonia, but  later  the  areas  of  dullness  become  distinctly  recognizable. 
As  the  disease  progresses,  the  fever  becomes  irregular,  sweating  is  often 
profuse,  and  frequent  chills  may  occur.  The  case  may  terminate' fatally 
within  three  weeks,  or  it  may  gradually  subside  into  a  chronic  condition 
lasting  for  several  months. 

(2)   Chronic   Ulcerative   Tuberculosis  of  the  Lungs. 

Morbid  Anatomy. — In  the  great  majority  of  cases  the  lesions  are  first 
found  in  one  or  both  apices,  usually  an  inch  or  more  below  the  sum- 
mit. From  this  point  the  process  passes  rapidly  or  slowly  downward. 
This  extension  of  the  disease  is  probably  in  part  a  result  of  the  aspi- 
ration of  the  sputum  or  caseous  matter  into  the  bronchial  tubes.  The 
new  growth  of  tubercles  is  then  located  in  the  tapering  extremity  of 
the  terminal  bronchus,  near  the  entrance  to  the  infundibulum.  From 
the  smaller  bronchi  the  process  may  extend  upward,  however,  to  the 
larger  tubes.  The  disease  extends  also  directly  from  the  affected  center 
to  adjacent  tissue.  It  may  follow  the  lymph  channels,  producing  a 
chain  of  young  tubercles  radiating  from  the  primary  center,  and  it  may 
be  carried  by  the  blood.  Autoinfection  no  doubt  occurs  as  the  result 
of  the  inhalation  of  dried  sputum  from  the  patient's  own  clothing, 
or  possibly  from  some  other  source.  The  disease  thus  progresses  from 
one  region  to  another  until  an  entire  lobe,  an  entire  lung,  or  a 
greater  part  of  both  lungs  becomes  converted  into  a  mass  of  tuber- 
cular tissue  in  different  stages  of  growth  and  degeneration. 

The  processes  of  infiltration,  caseation,  and  sclerosis  have  been  con- 
sidered under  the  head  of  Morbid  Anatomy  of  Tubercle.  As  a  result 
of  these  processes  many  different  conditions  are  produced.  Caseation 
leads  to  necrosis  of  the  tissues  and  ulceration,  with  the  formation  of 
cavities.  This  frequently  occurs  in  the  wall  of  a  bronchial  tube.  As  a 
result,  the  wail  is  rendered  thin  and  less  resistant  to  the  expansive  force 
of  the  air  in  coughing.  The  walls  stretch  and  form  fusiform  dilatations 
(bronchiectatic  cavities).  The  further  destruction  of  the  tissues  is  often 
hastened  by  the  entrance  of  pus-forming  germs  into  these  cavities.  The 
necrotic  destruction  may  begin,  however,  among  the  air-cells,  particu- 
larly in  the  apex.  Recent  cavities,  still  in  a  state  of  formation,  have 
uneven,  ragged  surfaces  or  they  are  lined  with  caseous  debris.     Such 


Practice  of  Medicine.— French. 


PLATE  II 


Diffuse  and  Focal  (Chronic)  Pulmonary  Tuberculosis — 
"  Chronic  Phthisis." 

In  the  upper  third  of  the  lung  there  is  tuberculous  broncho-pneu- 
monia with  commencing  ulceration  of  small  bronchi :  nearly  complete 
consolidation  from  the  extension  and  coalescence  of  small  tuberculous 
foci  and  diffuse  formation  of  fibrous  tissue. 

In  the  lower  third  of  the  lung  are  irregular,  dense,  sharply  outlined 
tuberculous  foci  (chronic  miliary  tubercles). 

In  the  middle  third  there  is  tuberculous  pneumonia  of  the  exuda- 
tive type,  the  incompletely  consolidated  areas  having  become,  in  part, 
caseous. 

The  less  involved  portions  of  the  lung  in  this,  as  in  the  other 
injected  specimens,  are  the  darker. 

(Zfy permission,  frotn  ' '' Delajield and Prudden.") 


TUBERCULOSIS  195 

cavities  may  surround  a  small  blood-vessel  or  a  bronchus,  and  the  end 
of  a  small  bronchial  tube  sometimes  protrudes  into  them.  A  blood- 
vessel thus  surrounded  becomes  inflamed,  and  an  endarteritis  obliterans 
is  developed,  often  completely  closing  the  vessel.  Old  cavities  are  usually 
smooth  and  lined  with  firm  (pyogenic)  membrane,  upon  which  pus  is 
constantly  formed.  The  largest  cavities  are  generally  a  result  of  the 
coalescence  of  several  smaller  ones.  In  this  manner  an  entire  lobe,  al- 
most an  entire  lung,  may  be  excavated. 

When  the  tubercular  process  is  situated  near  the  surface  of  the  lung,  the 
pleura  invariably  becomes  inflamed  and  later  infiltrated  with  tubercles. 
A  small  cavity  immediately  under  the  pleura  sometimes  breaks  through 
it  and  produces  a  pneumothorax,  by  permitting  the  escape  of  air. 
This  accident  is  generally  prevented,  however,  by  the  inflammatory 
process,  which  rapidly  forms  adhesions  between  the  two  layers  of  the 
membrane.  This  adhesive  inflammation  is  sometimes  so  extensive  that 
almost  the  entire  pleural  cavity  of  one  side  becomes  obliterated.  Very 
rarely  a  cavity  evacuates  its  contents  through  the  chest-wall. 

Sclerosis  is  a  reparative  process,  but  it  seldom  results  in  the  com- 
plete repair  of  the  tubercular  lesions,  except,  perhaps,  in  the  earliest  stage. 
In  some  other  instances  it  separates  the  caseous  masses  from  the  sur- 
rounding tissue  by  a  firm  wall,  and  occasionally  it  closes  small  cavities 
after  they  have  discharged  their  contents.  Calcification  may  follow 
either  caseation  or  sclerosis,  but  more  frequently  the  former.  Its  oc- 
currence does  not  always  indicate  an  arrest  of  the  tubercular  process, 
for  Hving  bacilH  may  remain  in  the  periphery  of  the  calcified  nodule. 
An  awakening  of  the  process  with  the  destruction  of  surrounding  tissue 
sometimes  causes  the  discharge  of  small  calcified  masses  in  the  form  of 
the  so-called  lung-stones. 

The  bronchial  glands  are  also  implicated  in  all  cases.  In  the  more 
acute  they  become  swollen  and  edematous;  they  are  nearly  always  tu- 
bercular. Caseation  occurs  in  them,  and,  in  the  chronic  cases,  calci- 
fication.    Suppuration  sometimes  occurs. 

Other  Organs. — Important  changes  occur  in  other  organs,  especially 
the  larynx,  intestine,  liver,  spleen,  kidneys,  pericardium,  and  cerebral  me- 
ninges. Many  of  the  changes  are  tubercular  in  character.  As  a  result, 
no  doubt,  of  the  toxemia  and  anemia,  degenerations  are  common,  es- 
pecially in  the  organs  just  enumerated.  The  hver  is  the  seat,  also,  of 
extensive  fatty  infiltration.  Amyloid  degeneration  is  of  common  occur- 
rence in  the  more  chronic  cases  and  affects  particularly  the  intestines, 
liver,  spleen,  and  kidneys. 

Symptoms. — Mode  of  Onset. — (jx)  In  many  cases  the  disease  remains 
for  a  time  latent.  Considerable  progress  is  often  made  by  it  before 
the  infection  is  recognized.  In  some  instances  it  advances  to  the  forma- 
tion of  a  cavity  in  one  of  the  apices  before  the  patient  realizes  his  ill- 
ness. In  other  cases  the  greater  prominence  of  symptoms  on  the  part 
of  other  organs  may  not  only  mask  the  pulmonary  condition,  but  it 
may  for  a  time  mislead  both  the  patient  and  his  physician.  The  most 
common  of  these  conditions  are  the  tubercular  aff'ections  of  the  bones 
and  joints,  caries  of  the  vertebrae,  ribs,  sternum,  or  lymph-glands,  lum- 
bar and  psoas  abscesses,  otitis,  and  anal  fistula. 

(Ji)    With  Cough.— \n   probably   the   greatest   number    of  cases    the 


196  PRACTICE  OF  MEDICIx\E 

disease  begins  with  the  symptoms  of  bronchitis.  The  patient  has  per- 
haps suffered  for  years  from  a  nasopharyngeal  catarrh,  with  great  sus- 
ceptibiUty  to  "cold."  These  attacks  grow  more  severe,  or  after  some 
unusual  exposure  a  severe  bronchial  catarrh  develops.  The  sputum 
becomes  mucopurulent,  and  there  may  be  a  slight  elevation  of  the  even- 
ing temperature.  Dyspnea  is  often  a  noticeable  accompaniment,  and  it 
sometimes  assumes  a  paroxysmal  form  resembling  asthma. 

(^)  A7iemia  is  often  one  of  the  earliest  symptoms.  It  is  recognizable, 
however,  by  the  cardiac  palpitation,  indigestion,  or  perhaps  amenorrhea 
which  results  from  it,  rather  than  by  the  appearance  of  the  patient. 
The  blood  usually  shows  reduction  of  hemoglobin,  of  2  5  per  cent  or  more, 
and  leucocytosis,  becoming  more  pronounced  as  the  disease  progresses. 
The  red  corpuscles  are  often  normal  in  number,  and  the  blood-plates 
greatly  increased. 

(^3  Dyspepsia. — Many  cases  begin  with  an  acid  dyspepsia,  character- 
ized by  eructations,  vomiting,  or  pain  and  a  sense  of  burning  in  the 
stomach.  The  connection  of  this  symptom  with  the  affection  of  the  lung 
is  probably  often  overlooked. 

{/)  Hemoptysis. — The  existence  of  the  disease  is  often  announced  by 
a  more  or  less  profuse  hemorrhage  of  the  lungs.  Repeated  hemorrhages 
sometimes  occur.  After  a  hemorrhage  the  disease  sometimes  remains 
for  a  long  time  quiescent,  but  in  most  cases  the  tubercular  process  ad- 
vances with  greater  rapidity. 

(_/)  Pleurisy. — The  first  symptom  to  attract  attention  in  some  cases 
is  pleurisy,  with  dry  friction-sounds  over  the  apex.  The  disease  may  also 
follow  a  pleurisy  with  exudation.  The  cough  persists  after  the  effusion 
has  been  absorbed,  and  a  localized  tubercular  process  may  soon  become 
recognizable. 

(^)  Chills. — In  some  cases  the  onset  is  accompanied  with  chills,  fever, 
and  sweating  not  unlike  those  of  malaria  or  sepsis.  It  is  not  uncom- 
mon to  elicit  a  history  of  slight  chills  at  a  time  corresponding  to  the 
beginning  of  the  infection  in  cases  that  have  been  characterized  by  a 
greater  prominence  of  other  manifestations.  The  hectic  flush  of  the 
cheeks  in  the  afternoons  soon  becomes  apparent  in  these  cases,  and  a 
close  watch  of  the  temperature  at  short  intervals  will  reveal  an  irregular 
curve  quite  unlike  that  of  malaria,  though  more  like  that  of  sepsis. 

(/^)  With  Laryngeal  Symptoms. — In  a  fairly  large  group  of  cases  there 
is  a  history  of  periodic  hoarseness  or  aphonia  preceding  the  recognized 
onset  of  the  disease.  It  is  only  in  a  small  minority  of  these  cases, 
however,  that  the  larynx  is  the  primary  seat  of  the  infection,  and  such 
manifestations  disappear  more  or  less  permanently  after  the  pulmonary 
disease  has  become  far  advanced. 

(0  Enlarged  Lymph- Glands. — Tubercular  enlargement  of  the  lymph- 
glands  of  one  side  of  the  neck,  particularly  those  of  the  supraclavicular 
region,  and  often  associated  with  enlargement  of  the  axillary  glands 
of  the  same  side,  has  often  been  recognized  for  months  or  years  before 
the  development  of  recognizable  lesions  in  the  lungs. 

Typical  Course. — From  the  great  variety  of  clinical  pictures  presented 
in  this  heterogeneous  disease  it  is  difficult  to  select  one  that  can  be 
called  typical.  Few  cases  are  alike,  yet  there  is  a  train  of  symptoms 
that  are  more  or  less  common  to  a  majority  of  them. 


TUBERCULOSIS 


197 


The  classical  description  of  the  disease  divides  its  course  into  three 
stages,  designated  by  the  old  Latin  writers :  phthisis  incipiens,  phthisis 
confirmata,  and  phthisis  desperata.  These  stages  correspond  to  the 
more  modern  description  of  the  development  of  tubercles,  their  soften- 
ing, and  the  formation  of  cavities.  And  although  this  division  is  little 
employed  at  the  present  time,  it  is  more  or  less  clearly  apparent  in 
many  cases. 

In  the  early  stage  there  is  the  persistent  cough.  It  may  be  a  per- 
sistent hacking  little  noticed  by  the  patient  during  his  busy  moments, 
and  it  may  become  troublesome  only  when  he  lies  down  or  arises  in  the 
morning.  The  expectoration  is  generally  slight  and  of  a  clear  mucous 
character;  occasionally  it  is  streaked  with  a  little  blood.  The  appetite 
is  lost  or  becomes  capricious,  and  the  digestion  becomes  feeble,  the 
bowels  are  generally  constipated,  but  diarrhea  sometimes  develops.  The 
patient  grows  anemic  and  he  loses  flesh;  his  strength  fails,  and  slight 
exertion  causes  dyspnea  and  rapid  breathing.  The  heart's  action  also 
becomes  irritable.  Slight  elevation  of  temperature  may  generally  be 
observed  at  this  time,  but  not  always  at  any  definite  time  of  the  day. 
In  many  cases  there  is  the  cachectic  flush  with  slight  fever  toward  even- 
ing. An  elevation  of  the  temperature  on  the  affected  side  amounting  to 
1°  or  2°  F.  (0.5° — 1.5°  C.)  has  been  observed  by  Peter,  but  it  is  not 
invariably  present.  Night-sweats  are  often  an  important  symptom. 
All  these  manifestations  may  develop  in  the  course  of  a  few  weeks,  or 
they  may  occupy  as  much  as  two  or  three  years.  Recovery  is  possible 
in  the  less  rapid  cases,  but  as  a  rule  there  are  alternating  periods  of 
improvement  and  decline.  As  the  disease  progresses,  the  patient's  ap- 
pearance becomes  distinctive.  The  face  becomes  drawn  or  pinched,  the 
expression  anxious;  the  cheeks  appear  hollow  and  the  eyes  sunken, 
though  still  bright;  the  skin  becomes  sallow,  sometimes  appearing 
stretched;  the  finger-ends  become  thick  or  clubbed  and  the  nails  incur- 
vated  (Hippocratic  fingers)  and  blue.  The  patient,  always  hopeful, 
still  boasts  of  his  strength,  while  his  cheeks  are  flushed  and  his  breath- 
ing short.  Every  cold  contracted,  every  attack  of  indigestion,  every 
fatigue,  hastens  the  decline.  Winter  is  the  worst  season  for  the  consump- 
tive. The  cough  then  becomes  more  severe,  the  expectoration  more 
abundant  and  more  purulent.  Microscopic  examination  of  the  sputum 
reveals  numerous  bacilli  and  frequently  the  elastic  tissue  from  the  lungs. 
Numerous  micrococci  are  also  present  in  some  cases.  From  the  begin- 
ning of  cavity-formation,  much  depends  upon  the  physical  endurance 
and  resoluteness  of  the  patient.  Many  persons,  through  sheer  deter- 
mination, continue  their  usual  pursuits  until  the  most  advanced  stage 
is  reached ;  others  yield  more  readily  to  the  growing  inclination  to  rest. 
Sooner  or  later  in  all  cases  there  comes  a  time  when  the  bed  becomes  the 
mercy-seat.  Each  day  it  is  longer  occupied  and  returned  to  with  less 
reluctance.  The  fever  becomes  high,  the  emaciation  advances  more 
rapidly,  and  the  weakness  grows  more  extreme.  The  approach  of  death 
becomes  more  and  more  apparent  to  all  but  the  patient.  The  end  is 
often  hastened  by  a  colliquitive  diarrhea  which  generally  indicates  the 
implication  of  the  intestine  in  the  tubercular  process,  but  in  other  cases 
the  decline  is  long  drawn  out  and  life  hangs  as  by  a  thread  for  days 
and  weeks.    The  end  comes  peacefully  in  a  coma  or  amidst  pitiful  Strug- 


1 98  PRACTICE  OF  MEDICINE 

gles  against  the  inevitable.  The  average  duration  of  the  disease  in  i,ooo 
cases  among  the  upper  classes  in  England  was  found  by  C.  J.  and  C.  T. 
Williams  to  be  7  years  and  8.72  months.  Among  the  lower  classes  it 
is  much  shorter. 

Special  Symptoms. — Local. — (i)  Cough  is  one  of  the  most  constant 
symptoms  throughout  the  disease.  In  the  beginning  it  may  be  so  slight 
as  to  attract  little  attention;  the  patient  is  often  little  aware  of  it, 
but  later  it  is  often  so  distressing  as  to  interfere  with  sleep.  It  is  often 
out  of  proportion  to  the  evidences  of  pulmonary  involvement,  being 
sometimes  excessive,  sometimes  unaccountably  mild.  It  is  at  first 
bronchial  in  character,  but  after  the  formation  of  cavities  it  becomes 
paroxysmal,  and  it  is  aroused  more  particularly  by  changes  of  position, 
as  when  the  patient  lies  down  or  arises  from  sleep.  Not  infrequently 
the  paroxysms  induce  vomiting.  The  sound  of  the  cough  is  often  pecu- 
liarly hollow.  It  becomes  husky  or  hoarse  when  the  vocal  cords  are 
involved. 

(2)  The  Sputum.— (jC)  The  quantity  of  sputum  is  exceedingly  variable. 
In  some  cases,  even  after  months  of  constant  cough,  there  may  be 
scarcely  a  trace  of  it,  while  in  others  the  expectoration  is  profuse  from 

the  beginning.  After  large  cavities 
have  formed,  the  quantity  sometimes 
becomes  enormous;  a  pint  (500  c.c.) 
may  be  expectorated  in  24  hours.  The 
sputum  at  first  consists  of  clear,  glary 
mucus  from  the  bronchial  tubes,  or  it 
may  consist  largely  of  alveolar  epi- 
thelium in  a  state  of  myelinic  degene- 
ration. It  contains  numerous  small 
air  bubbles  and  floats  on  the  surface 
of  water.  The  appearance  of  small 
grayish  or  yellow,  purulent  masses  is 
Fig.  1 3. -Tubercle  bacilli  in  sputum.      ^^^^  distinctive,  for  it  is  in  them  that 

the  tubercle  bacilli  are  most  numerous.  As  the  caseous  nodules  in  the 
lung  begin  to  soften,  the  sputum  becomes  more  abundant  and  assumes  a 
more  uniformly  purulent  appearance.  It  is  often  expectorated  in  coinhke 
(nummular)  masses  which  sink  in  water.  The  only  pathognomonic 
feature  of  tuberculous  sputum,  however,  is  the  presence  of  the  bacilli. 
When  these  exist  in  it,  the  case  is  always  one  of  tuberculosis.  They  may 
be  few  or  many.  When  only  one  or  two  are  found  or  when  they  are 
absent  from  the  sputum  of  a  suspicious  case,  repeated  examinations 
should  be  made,  for  the  presence  of  a  few  may  be  accidental,  and  their 
supposed  absence  may  be  due  to  faulty  technique  in  the  collection  of 
the  sputum  or  in  the  process  of  staining.  (For  methods  of  staining, 
see  p.  748.) 

Other  bacteria  are  not  infrequently  found,  particularly  when  large 
cavities  exist.  They  are  especially  streptococci,  occasionally  staphylo- 
cocci and  pneumococci.  Sarcinae  are  sometimes  present,  and  such  fungi 
as  the  aspergillus  even  more  frequently. 

(^)  Elastic  Tissue.— TMx's,  is  found  only  after  the  affected  tissue  has 
begun  to  disintegrate.  It  may  be  derived  from  the  bronchial  tubes,  the  al- 
veoli, or  the  walls  of  the  arteries.    That  from  the  bronchi  forms  an  elon- 


TUBERCULOSIS 


199 


Fig.  14.— Elas- 
tic tissue  in  spu- 
tum. 


gated  network,  or  several  long,  slender  fibers  may  lie  close  together ;  that 
from  the  blood-vessels  may  have  the  same  appearance,  but  thin  sheets, 
like  fragments  of  the  intima,  are  sometimes  found.  The  alveolar  elastic 
tissue  is  generally  branched  and  it  may  retain  the  outhne  of  the  air-cells, 
as  in  Fig.  15. 

(f)   Blood. — This  is  sometimes  only  sufficient  to  tinge        /^ 
the  sputum,  and  it  may  be  recognized  only  on  microscopic        \^ 
examination.     When  hemoptysis  occurs,  blood  is  the  chief 
element  of  the  expectorated  matter.     It  has  a  bright  red 
color  and  is  usually  so- intimately  mingled  with  air  as  to 
appear  frothy. 

(^(T)  Calcareous  Fartides. — These  are  only  occasionally 
found  and  their  discovery  is  of  little  significance  further 
than  the  fact  that  there  must  be  some  disintegration  of 
lung  tissue  to  permit  their  escape  from  the  tissues  in  which 
they  were  embedded.  They  represent  calcified  tubercular 
nodules.  In  size  they  vary  from  a  millet-seed  to  a  cherry. 
Only  one  or  quite  a  number  may  be  coughed  up.  They  occasionally 
originate  in  a  bronchial  gland  which  has  ulcerated  into  a  bronchial 
tube. 

(3)  Pain  is  not  usually  a  prominent  symptom.  It  may  be  absent 
throughout  the  disease.  In  many  cases  there  is,  however,  a  constant 
sense  of  discomfort  in  the  affected  part  of  the  lung,  which  becomes  a 
more  or  less  severe  pain  upon  coughing.  Sometimes  there  is  sharp, 
lancinating  pain  as  a  result  of  involvement  of  the  pleura.  When  the 
cough  is  very  troublesome,  the  lower  portion  of  the  chest  often  becomes 
painful,    in    part,    perhaps,    from    the 

muscular  exertion.  Periodic  attacks  of 
pleurisy  or  intercostal  neuralgia  are  not 
uncommon  during  the  disease. 

(4)  Dysp?iea  is  often  absent  except 
as  it  may  result  from  exertion.  In 
some  cases,  on  the  other  hand,  it  is  a 
prominent  symptom  from  the  begin- 
ning; it  may  even  become  less  pro- 
nounced as  the  disease  advances.  In 
the  more  acute  cases  the  respiration 
often  becomes  rapid,  but  when  the 
process  is  slower  it  may  be  but  little 
accelerated,  even  after  an  entire  lung 
has  become  solidified.  A  cardiac 
dyspnea  may  develop  in  cases  com- 
plicated with  hypertrophy  or  rapid 
action  of  the  heart.  In  some  cases 
occasional  attacks  resembling  asthma 
occur. 

(5)  Hemoptysis.— ^^vcioxx\xd.g^  of  the  lungs  occurs  in  from  60  to 
80  per  cent  of  cases.  It  is  nearly  five  times  more  frequent  in  men  than 
in  women.  It  occurs  early  in  the  disease,  often  before  the  existence 
of  recognizable  lesions;  or  late,  after  the  formation  of  large  cavities. 
The    early  hemorrhage  sometimes  follows  a  gradual  decline  of  health, 


Fig.    15.— Elastic    tissue  with 
thelium  and  bacteria. 


epi- 


2  00  PRACTICE  OF  MEDICINE 

with  anemia,  slight  cough,  or  indigestion,  but  it  often  attacks  without 
warning  young  healthy  individuals  free  from  predisposition  to  tubercu- 
losis or  recognizable  tuberculous  taint.  Although  such  hemorrhages 
are  regarded  as  of  tuberculous  origin,  physical  examination  fails  to  re- 
veal it,  and  the  sputum  often  contains  no  bacilli.  Not  infrequently  the 
patient  continues  in  good  health.  In  another  group  of  cases  the  hemor- 
rhage follows  some  unusual  exertion,  as  swimming  or  athletic  sport; 
no  recognizable  lesion  may  exist,  but  the  sputum  contains  bacilli.  The 
quantity  of  blood  is  usually  small,  only  a  dram  or  two,  perhaps ;  fatal 
hemorrhage  is  exceedingly  rare.  In  most  cases  repeated  hemorrhages 
occur.  They  are  sometimes  so  frequent  as  to  justify  the  appellation 
hemorrhagic  phthisis,  given  to  the  condition  by  some  authors. 

Late  hemorrhages  are  more  frequently  profuse;  a  pint  or  more  of 
blood  may  be  lost  within  a  few  minutes,  and  a  fatal  syncope  may  result. 
The  blood  usually  comes  from  the  erosion  of  an  artery  or  the  rupture 
of  a  small  aneurism  within  a  cavity.  A  fatal  termination  is  more  apt 
to  follow  a  succession  of  profuse  hemorrhages.  Thirst  and  dyspnea 
result  from  the  loss  of  blood.  The  pallor  which  is  present  is  in  part 
anemic,  in  part  a  result  of  the  alarm  occasioned  by  the  hemorrhage. 
In  some  instances  the  blood  is  retained  within  a  large  cavity  and  is  not 
ejected.  The  other  symptoms  are  dyspnea,  thirst,  sometimes  sigh- 
ing or  yawning,  and  a  bloodlike  odor  may  be  detected.  After  a  hemor- 
rhage, blood  continues  to  appear  in  the  sputum  for  several  days,  but 
its  color  becomes  darker.  In  some  cases  an  oozing  from  small  vessels 
within  a  cavity  may  keep  up  the  expectoration  of  bright  arterial  blood 
for  a  much  longer  time,  and  the  appearance  of  hemorrhage  is  maintained. 
The  more  remote  effects  of  hemorrhage  are  very  different  in  different 
cases.  Improvement  sometimes  follows,  for  a  time  at  least,  but  in  a 
majority  of  cases  the  progress  of  the  disease  becomes  more  rapid. 

General  Symptoms. — (i)  Fever. — This  is  oneof  the  most  important  feat- 
ures of  the  disease,  its  presence  being  especially  valuable  in  prognosis,, 
for  fever  denotes  waste  and  loss  of  strength;  its  absence  indicates  a 
possibility  of  improvement.  In  the  early  stages,  the  presence  of  slight 
fever  is  apt  to  escape  observation,  unless  the  temperature  be  taken  at 
comparatively  short  intervals,  as  once  every  two  hours.  The  highest 
temperature  usually  occurs  between  2  and  6  p.m.,  the  lowest  between 
2  and  6  a.m.  In  not  a  few  cases  the  temperature  becomes  subnormal 
in  the  early  morning  hours.  Yet  many  cases  reach  an  advanced  stage 
without  fever.  Frequent  observations  will  usually  show  slight  elevation 
of  temperature  after  exercise  or  excitement  of  any  kind.  The  fever  of 
the  early  stages  is  probably  of  different  origin  from  that  of  the  late 
stages.  It  is  doubtless  due  to  the  tuberculization  or  advance  of  the 
tubercular  process  within  the  lungs,  being  produced,  no  doubt,  by  the 
absorption  of  toxins,  since  the  same  effect  is  produced  by  the  injection 
of  tuberculin.  In  the  late  stages  it  may  be  due  to  the  same  influence, 
but  it  is  often  septic  in  character,  and  possibly  arises  from  mixed  infec- 
tion and  absorption  of  other  toxins  than  those  of  the  tubercle  bacillus. 
The  fever  may  be  either  remittent  or  intermittent  in  type.  Either  form 
may  occur  in  either  stage,  and  the  two  sometimes  alternate  as  the  proc- 
esses in  the  lungs  change  from  time  to  time.  The  occurrence  of  a  daily 
chill  followed  by  fever  and  sweating  is  not  uncommon,  and  it  is,  perhaps,, 


TUBERCULOSIS  201 

often  mistaken  for  malarial  infection.  The  fever  of  the  advanced  stages 
is  more  apt  to  be  continuous;  and  the  more  rapid  the  processes  of 
softening  and  suppuration,  the  less  will  be  the  iluctuation  of  tempera- 
ture. A  fluctuation  of  only  a  degree  or  two  is  also  suggestive  of  the 
presence  of  tubercular  pneumonia,  which  may  develop  at  any  time  dur- 
ing the  course  of  the  disease.  A  wide  range  from  day  to  day  is  highly 
characteristic  of  tuberculosis,  for  there  is  often  a  difference  of  from  3  ° 
to  5°  F.  (1.5°  to  2.5°  C).  The  curve  may  be  constantly  above  nor- 
mal or  it  may  drop  several  degrees  below  in  the  night-time.  After 
hemoptysis  the  temperature  is  often  higher,  possibly  in  part  from  the 
absorption  of  altered  blood,  but  often  on  account  of  the  catarrhal  pneu- 
monia that  is  developed. 

(2)  Sweating. — Profuse  sweating  is  often  a  serious  symptom.  It  most 
frequently  assumes  the  character  of  night-sweats,  occurring  as  the  fever 
drops  in  the  early  morning  hours,  but  often  also  during  a  nap  in  the 
daytime.  It  is  more  common  after  the  disease  has  become  advanced, 
but  it  may  be  present  from  an  early  stage.  Some  patients  are  so  for- 
tunate as  to  escape  it  altogether. 

(3)  Pulse. — In  acute  cases  the  pulse  becomes  rapid,  from  100  to  120 
or  higher.  The  rate  does  not  always  correspond  to  the  temperature, 
and  the  acceleration  may  not  develop  until  several  days  after  the  dis- 
covery of  fever.  In  chronic  cases  the  pulse  may  remain  normal,  full  or 
small,  regular  or  irregular ;  it  is  generally  regular,  but  weak  and  soft.  A 
capillary  or  venous  pulsation  may  sometimes  be  seen,  the  latter  especially 
on  the  backs  of  the  hands.  A  dicrotic  pulse  is  oftener  observed  in  this 
than  in  any  other  chronic  disease  (Vierordt). 

(4)  Respiration. — A  careful  count  usually  shows  increased  activity 
of  respiration.  It  may  be  slight  in  early,  mild  cases.  WTien  there  is 
involvement  of  a  large  area  of  lung  tissue  and  when  fever  develops, 
however,  the  breathing  becomes  more  accelerated.  The  ratio  of  the 
respiration  to  the  pulse  is  usually  maintained.  An  intensely  fetid  odor 
of  the  breath  is  not  infrequently  noticeable.  It  is  usually  indicative  of 
a  mixed  infection. 

(5)  Emaciation. — Next  to  the  temperature  chart,  the  record  of  weight 
gives  the  most  valuable  indication  of  the  progress  of  the  disease.  A 
gradual  decline  is  the  rule,  although  it  may  amount  to  so  little  as  not 
to  be  observed  without  actual  weighing.  In  febrile  cases  the  emaciation 
progresses  with  greatest  rapidity. 

(6)  Psychical  State. — One  of  the  most  striking  features  in  many  cases  is 
the  hopefulness  of  the  patient,  a  pleasing  delusion  of  recovery  which 
clings  to  the  last  and  should  not  be  dispelled. 

Physical  Signs. — (<?)  Inspectioii. — The  typically  phthisical  chest  is  long 
and  narrow,  or  broad  and  flat,  with  abnormal  straightness  of  the  upper 
ribs  and  obliquity  of  the  lower.  The  scapulee  are  winged.  In  the  long, 
narrow  chest  the  intercostal  spaces  are  usually  wide;  in  the  flat  chest 
they  are  sunken  and  the  sternum  may  be  depressed,  the  lower  portion 
often  deeply  concave.  The  supra-  and  infraclavicular  spaces  of  the  af- 
fected side  are  often  more  depressed  than  those  of  the  normal  side. 
The  diminished  expansion  of  the  defective  side  is  also  distinctly  notice- 
able, particularly  if  looked  at  from  above.  Osier  calls  attention  to  the 
importance  of  observing  the  condition  of  the  precordia,  as  a  wide  area 


2  02  PRACTICE  OF  MEDICINE 

of  impulse,   particularly  in  the  second,  third,  and  fourth  interspaces,  is 
often  associated  with  chronic  tuberculosis  of  the  left  apex. 

((5)  Palpation.— T\\^  disparity  of  expansion  can  be  better  recognized 
by  this  method,  especially  by  standing  behind  the  patient  and  placing 
the  thumbs  in  the  supraclavicular  and  the  fingers  in  the  infraclavicular 
region.  An  increased  vocal  fremitus  can  often  be  detected  over  the 
affected  area  before  it  is  revealed  by  other  methods.  Allowance  must  be 
made  for  the  normally  stronger  fremitus  of  the  right  side.  It  is  more 
markedly  exaggerated  over  a  cavity.  Thickening  of  the  pleura  and  the 
presence  of  fluid  in  the  pleural  cavity  diminish  or  entirely  arrest  the 
transmission  of  the  fremitus. 

((t)  Percussion.— \t  is  seldom  that  much  can  be  learned  from  percus- 
sion in  the  incipient  stage.  In  some  cases  slight  dullness  may  be  ehcited, 
over  the  affected  apex,  by  percussion  upon  the  clavicle  or  above  or  below 
it.  Percussion  with  the  breath  held  in  full  inspiration  is  more  certain 
to  bring  out  dullness.  The  note  is  often  sHghtly  tympanitic  (tympanitic 
dullness).  Absolute  flatness  is  obtained  only  over  large  areas  of  con- 
soHdation;  a  full  tympanitic  note  or  a  cracked-pot  sound,  only  over 
thin-walled  cavities  of  considerable  size.  Neither  of  these  sounds  is  trust- 
worthy in  children,  however,  since  they  may  be  brought  out  by  forcible 
percussion  of  the  normal  chest.  The  sense  of  increased  resistance  im- 
parted to  the  finger  is  often  of  as  much  value  as  the  tone,  and  it  is 
often  more  easily  recognized.  A  fibrillary  contraction,  or  mounding, 
of  the  pectoral  muscle  (myoidema)  is  often  an  interesting  phenomenon 
during  percussion.  It  is,  however,  without  especial  relation  to  the 
disease. 

(<^)  Auscultation.— Y^vtry  deviation  from  the  normal  vesicular  murmur 
and  every  adventitious  sound  may  be  heard  in  the  course  of  the  disease. 
In  the  early  stages  the  evidence  obtained  from  auscultation  is  not  al- 
ways conclusive.  There  is  at  first,  perhaps,  only  a  slight  feebleness  of 
the  vesicular  murmur,  or  it  may  become  entirely  inaudible  owdng  to 
the  diminution  in  the  amount  of  air  entering  the  air-cells.  A  little  later 
the  murmur  becomes  higher  in  pitch  or  harsh,  and  with  this  the  ex- 
piratory murmur  is  slightly  prolonged.  The  rhythm  often  becomes 
wavy  or  jerky,  or  it  is  described  as  a  cog-wheel  respiration.  A  slight 
pleuritic  friction  is  sometimes  heard  for  a  considerable  length  of  time 
iDefore  other  evidence  of  the  disease  becomes  apparent.  This  sound  is 
distinguished  with  difficulty,  however,  from  the  dry,  subcrepitant,  almost 
crepitant  rales  that  are  sometimes  heard  at  the  end  of  a  full  inspira- 
tion in  this  early  stage.  \^Tien  moist  rales  are  heard  in  the  initial 
stage,  they  are  usually  due  to  the  coexistent  bronchitis.  Coughing 
sometimes  removes  the  rales,  sometimes  itserves  to  render  them  more 
audible. 

As  consolidation  becomes  more  fully  developed,  the  respiratory  mur- 
mur is  replaced  by  tubular  breathing,  the  vocal  resonance  is  increased, 
and  bronchophony  may  be  heard.  The  whispered  voice  is  also  rendered 
higher  in  pitch  and  more  concentrated.  Complete  consolidaton  of  a 
large  area  sometimes  arrests  all  sounds,  owing  to  the  loss  of  respiratory 
movement.  As  a  rule  such  silence  is  indicative  of  hydrothorax,  especially 
when  it  is  confined  to  the  lower  part  of  the  chest.  The  moist  rales  of 
bronchitis    are    often  heard  with  greater  distinctness  through  an  area 


TUBERCULOSIS 


203 


of  solidification.    With  the  occurrence  of  softening,  the  moist  rales  become 
louder  and  more  numerous,  usually  coarser  in  quality. 

The  formation  of  a  cavity,  after  it  has  attained  the  size  of  a  walnut 
or  larger,  leads  to  the  production  of  many  more  or  less  distinctive 
sounds.  The  respiratory  murmur  becomes  cavernous  or  amphoric  in 
character  over  the  cavity.  The  vocal  resonance  is  increased,  concen- 
trated, and  raised  in  pitch,  not  infrequently  attaining  the  quality  of 
pectoriloquy,  when  the  voice  seems  to  emanate  directly  from  the  chest. 
If  the  cavity  be  surrounded  by  solidified  lung  there  is  often  a  peculiar 
combination  of  bronchophony  and  pectoriloquy.  Egophony  is  some- 
times heard.  A  closed,  full,  cavity  yields  no  respiratory  or  vocal  sound, 
but  when  open  and  only  partially  filled  it  usually  produces  numerous 
moist  rales,  yielding  bubbling,  gurgling,  or  hissing  sounds,  sometimes 
a  metallic  tinkle  or  crackling.  The  succussion  sound  has  been  obtained 
in  a  few  instances  from  cavities  of  unusually  large  size.  Pleuritic  friction 
sounds  may  be  established  at  any  time  in  any  region  as  a  result  of  the 
involvement  of  the  pleura.  Over  the  opposite  lung  and  over  unaffected 
portions  of  the  diseased  one,  the  vesicular  murmur  becomes  high  in 
pitch  and  slightly  roughened,  sometimes  puerile,  as  a  result  of  so-called 
compensatory  emphysema  or  hypertrophy. 

A  pleuropericardial  friction  is  sometimes  heard  over  the  cardiac 
region  when  the  intervening  lung  is  involved.  The  heart  sounds  are 
often  transmitted  through  a  cavity  with  unusual  distinctness. 

Comp/icafions  of  Pulmonary  Tuberculosis. — The  larynx  not  infre- 
quently becomes  tubercular  as  a  result  of  inoculation  with  the  virus 
from  the  affected  lungs.  Pleurisy  is  almost  invariably  present  sooner 
or  later.  It  may  be  simple  or  tubercular,  dry  or  accompanied  by 
effusion.  The  fluid  may  be  serous,  purulent,  or  hemorrhagic;  rarely 
chylous.  Pneumothorax  is  a  not  infrequent  complication  as  a  result 
of  the  rupture  of  a  cavity.  It  may  prove  fatal  within  a  few  days. 
Pyopneumothorax  is  less  frequent,  and  it  is  often  a  less  fatal  compli- 
cation. Pneumonia  frequently  occurs  as  a  terminal  affection.  It  is 
often  exceedingly  difficult  to  determine  whether  the  disease  is  tubercular 
in  character  or  due  to  the  pneumococcus.  Gangrene  of  the  lung  occa- 
sionally develops.  A  slight  dilatation  of  the  air-cells,  usually  referred  to 
as  compensatory  emphysema,  is  found  in  the  unaffected  parts  of  both 
lungs. 

Endocarditis  is  infrequent,  although  murmurs  are  often  heard  at  the 
apex  or  over  the  pulmonary  valve.  Vegetations  occur  most  frequently 
on  the  tricuspid  valve. 

Various  complications  are  met  with  on  the  part  of  the  alimentary 
canal.  The  appetite  is  early  lost  in  many  cases ;  there  may  be  a  loath- 
ing of  food,  nausea,  or  vomiting.  The  tongue  is  usually  furred,  and  a 
red  line  is  often  seen  upon  the  gums  which  was  once  erroneously  thought 
to  be  characteristic  of  the  disease.  Catarrhal  or  aphthous  ulcers  may 
occur  in  the  mouth,  esophagus,  or  stomach.  Gastric  dilatation  is  occa- 
sionally observed,  and  there  may  be  marked  changes  in  the  mucous 
membrane  with  corresponding  alterations  of  function.  The  acid  secre- 
tion may  be  increased  or  diminished.  In  other  cases,  however,  although 
there  may  be  persistent  indigestion,  anorexia,  and  vomiting,  compara- 
tively little  that  is  abnormal  can  be  found  in  the  stomach.    The  per- 


204  PRACTICE  OF  MEDICINE 

sistent  vomiting  in  such  cases  is  often  simply  a  result  of  excessive 
coughing. 

Constipation  is  usually  present,  but  diarrhea  may  occur  at  any  time. 
Late  in  the  disease  it  is  frequently  due  to  tubercular  disease  of  the  in- 
testine. In  some  cases,  however,  even  late,  it  is  the  result  of  simple 
catarrhal,  ulcerative,  or  amyloid  disease.  '  Hemorrhoids  are  often  present 
in  tuberculous  cases  and  prove  persistent  when  there  is  much  coughing. 
Anal  fistula  occurs  in  about  3.5  per  cent  of  the  cases  of  pulmonary 
tuberculosis. 

Albuminuria  is  not  unusual,  either  as  a  result  of  the  fever  or  of  nephri- 
tis. In  the  latter  form,  occurring  late  in  the  disease,  edema  generally 
develops,  and  casts  are  found  in  the  urine.  Amyloid  disease  of  the  kid- 
neys, a  not  infrequent  complication,  produces  similar  changes,  and  the 
urine  is  copious  and  of  light  color.  Pyelitis  and  cystitis,  with  pus 
and  sometimes  blood  in  the  urine,  are  often  late  complications.  Tuber- 
culosis of  the  testicle  is  often  encountered. 

A  peculiar  hypertrophy  of  the  mammary  glands  is  occasionally  seen,, 
especially  in  the  male  subject  of  chronic  tuberculosis. 

In  addition  to  the  anemic  pallor,  the  cachectic  flush,  and  the  cya- 
nosis which  are  frequently  seen,  the  skin  often  shows  pigmentation  over 
the  chest  (cloasma  phthisicum),  especially  when  the  peritoneum  is  in- 
volved; or  the  brown  stains  of  pityriasis  versicolor  on  the  chest  and 
back.  The  hair  of  the  head  and  beard  often  becomes  harsh  and  dry,, 
and  the  nails  brittle. 

Such  diseases  as  typhoid  fever,  measles,  erysipelas,  and  the  other  acute 
infections  may  occur  in  tuberculous  patients,  but  they  bear  no  relation, 
to  it.  Tuberculosis,  especially  of  the  serous  membranes,  is  a  not  infre- 
quent terminal  affection  in  chronic  heart  disease  and  in  chronic  arthritis- 
Mitral  and  more  especially  pulmonary  stenosis  and  aortic  aneurism, 
apparently  predispose  to  tuberculosis  of  the  lungs;  and  the  immunity 
of  patients  with  chronic  heart  disease  to  tuberculosis,  at  one  time 
thought  to  exist,  is  not  well  established. 

(5)  Fibroid  Phthisis. 

This  term  is  applied  to  a  form  of  chronic  tuberculosis  of  the  lungs 
in  which  the  hyperplasia  of  connective  tissue  predominates.  It  may  re- 
sult from  the  process  of  sclerosis  accompanying  the  tubercle-formation 
or  it  may  be  the  result  of  the  engrafting  of  tuberculosis  upon  a  lung" 
that  is  already  in  a  state  of  chronic  fibrosis  from  pneumonokoniosis  or 
other  occupational  irritation,  or  of  the  so-called  chronic  interstitial 
pneumonia.  In  like  manner,  it  may  follow  chronic  tubercular  broncho- 
pneumonia or  pleurisy.  In  the  primarily  tubercular  form  it  usually 
begins  in  the  apex  along  with  the  tubercular  process  and  advances  with 
it  to  the  inferior  portions  of  the  lung.  The  condition  produced  varies 
from  a  moderate  increase  of  the  fibrous  tissue  confined  to  a  single  apex 
to  the  almost  complete  transformation  of  the  entire  lung  into  dense, 
hard,  scarlike  tissue,  with  here  and  there  bronchiectatic  or  necrotic 
cavities,  lying  open  or  filled  with  caseous  or  calcareous  debris.  In  many 
cases  it  can  be  distinguished  from  the  nontubercular  form  of  fibroid 
phthisis  only  by  the  demonstration  of  tubercle  bacilh,   but  ordinarily 


Practice  of  Medicine.— French. 


PLATE  IV. 


Diffuse  (Chronic) 


Pulmonary  Tuberculosis — "  Chronic 
Phthisis." 


In  the  upper  half  of  the  lung  there  are  scattered  miliary  tubercles 
and  irregular  areas  of  consolidation,  ^vith  a  diffuse  formation  of  fibrous 
tissue;  the  pleura  is  thickened.  A  large  portion  of  the  lower  lobe  is 
densely  consolidated  from  tubercle  tissue  and  exudate  with  coagulation 
necrosis  of  the  involved  regions.  These  regions  are  light  in  color, 
dense,  hard,  and  bloodless.  Such  dead  caseous  areas  may  persist  for 
some  time,  or  may  soften  and  disintegrate,  giving  rise  to  cavities. 

( By  permission ,  from  ' '  Delafield  atid  Prudden. ' ') 


TUBERCULOSIS  205 

numerous  tubercular  nodules  can  be  distinguished  in  the  lesions.  (See 
Plate  IV.)  The  tissues  are  usually  deeply  pigmented.  When  the  primary 
irritation  has  reached  the  lung  through  the  bronchi,  as  in  cases  caused 
by  the  inhalation  of  dust,  the  fibrosis  is  largely  peribronchial;  and 
when  upon  the  surface,  as  in  chronic  tubercular  pleurisy,  the  fibrosis  is 
confined  to  the  periphery  of  the  lung. 

Symptoms. — The  clinical  manifestations  are  usually  those  of  a  rather 
mild,  slowly  progressing  pulmonary  tuberculosis — cough,  abundant,  pur- 
ulent expectoration,  dyspnea  on  exertion,  gradual  emaciation.  The  pa- 
tient usually  acquires  a  peculiarly  dull,  dusky  facies,  with  thick  bluish 
lips,  often  with  puffy  eyelids  and  congested  conjunctivae.  Fever  is  not 
common.  When  large  bronchiectatic  cavities  exist,  the  sputum  may  have 
a  fetid  odor  which  is  communicated  to  the  breath,  and  it  may  be  found 
to  contain,  in  addition  to  the  bacilli  and  other  organisms,  pus-cells,  elastic 
tissue,  and  peculiar  acicular  (Charcot-Leyden)  crystals.  Hemoptysis 
is  occasionally  the  direct  cause  of  death.  Both  lungs  are  often  involved. 
It  is  in  this  form  of  tuberculosis  that  the  clubbed  fingers  are  most 
markedly  developed. 

The  physical  signs  axe  often  distinctive.  The  affected  side  is  depressed 
from  the  shrinking  of  the  lung;  the  shoulder  may  be  lower  and  the  chest- 
wall  distinctly  sunken.  The  expansion  is  much  reduced.  The  affected 
area  yields  marked  dullness  on  percussion,  and  all  the  sounds  due  to  con- 
solidation and  cavity-formation  may  be  heard  upon  auscultation.  The 
areas  of  cardiac  dullness  and  impulse  are  usually  increased,  owing  to 
•  hypertrophy  of  the  right  ventricle,  and  the  heart  may  be  displaced  by 
the  contraction  of  the  fibrous  tissue  and  the  formation  of  pleuritic  ad- 
hesions. Amyloid  disease  of  the  viscera  is  especially  frequent  after  this 
form  of  tuberculosis.  Chronic  passive  hyperemia  of  the  liver  is  a  fre- 
quent result  of  the  obstruction  of  pulmonary  circulation,  and  dropsy 
develops  from  the  enfeeblement  of  the  heart's  action. 

4.  TUBERCULOSIS  OF  THE  CENTRAL  NERVOUS  SYSTEM. 

The  brain  is  more  frequently  the  seat  of  tubercular  infiltration  than 
the  cord.  In  both  locations  the  disease  is  usually  associated  with  tuber- 
cular meningitis.  An  interesting  form,  more  frequent  in  children,  is  that 
in  which  a  single  large  tubercle  is  developed  in  the  brain  substance. 
Symptoms  of  localization  corresponding  to  those  of  other  brain  tumors 
are  produced.  Multiple  tubercular  formations  are  also  met  with,  most 
frequently  in  the  cerebellum,  next  in  the  cerebrum,  seldom  in  the  pons 
or  cord.  They  vary  in  size  from  a  pea  to  an  orange,  rarely  even  larger. 
They  show  the  usual  changes — caseation,  calcification,  sometimes  lique- 
faction. They  are  generally  attached  to  the  meninges  when  of  large 
size,  and  they  not  infrequently  induce  inflammation  of  these  mem- 
branes. They  are  usually  associated  with  tuberculosis  of  other  organs, 
especially  of  the  lungs. 

5.    TUBERCULOSIS  OF  THE  CIRCULATORY  SYSTEM. 

The  myocardium  and  its  membranes  may  be  involved  in  acute  mili- 
ary tuberculosis,  and  caseous  nodules  are  occasionally  found  in  them 
in  chronic  pulmonary  tuberculosis  as  a  result  of  direct  extension  of  the 


2o6  PRACTICE  OF  MEDICINE 

disease.  True  tubercular  endocarditis  is  probably  less  frequent  than 
that  due  to  mixed  infection  with  the  streptococcus  and  the  staphylo- 
coccus. The  arteries  have  never  been  found  to  be  the  seat  of  primary 
tuberculosis,  but  they  often  become  the  seat  of  secondary  invasion. 
The  intima  and  muscular  coats  become  thickened  and  the  lumen  may  be 
obliterated.  The  larger  vessels  are  frequently  involved  in  the  suppura- 
tive disintegration  of  the  bronchial,  mediastinal,  and  other  lymph-glands. 
Infection  of  the  arteries  from  the  blood  is  rare,  but  Osier  records  a 
case  observed  by  Flexner  in  which  a  large  solitary  tubercle  was  found 
in  the  aorta  independently  of  external  connection. 

6.  TUBERCULOSIS  OF  THE  DIGESTIVE  SYSTEM. 

The  Mouth. — The  mucous  membrane  of  any  part  of  the  mouth  may 
become  inoculated  with  tubercle  bacilli  from  the  sputum  of  a  tuberculous 
patient.  A  tubercular  infiltration  followed  by  the  formation  of  rough, 
irregular  ulcers,  usually  having  a  caseous  base,  may  occur  on  the  lips, 
on  the  sides  or  dorsum  of  the  tongue,  or  elsewhere.  Anders  records  an 
apparently  primary  lesion  on  the  lip.  Such  ulcers  resemble  a  chancre 
or  epithelioma,  and  are  to  be  distinguished  from  them  chiefly  by  the  his- 
tory of  their  growth,  the  presence  of  tuberculosis  in  the  patient,  the  pres- 
ence of  bacilli  in  the  tissues,  and  the  eff'ects  of  antisyphilitic  treatment. 

The  tonsils  are  probably  oftener  the  avenue  of  entrance  to  the  bacilli 
than  is  generally  realized,  particularly  in  cases  in  which  the  cervical 
lymph-glands  are  involved.  The  inoculation  generally  occurs  from  the. 
sputum  or  possibly  from  tubercles  in  the  food.  The  tonsil  becomes  en- 
larged by  the  tubercular  infiltration,  but  the  condition  is  distinguished 
with  great  difificulty  from  a  simple  follicular  enlargement.  Ulceration 
usually  follows. 

The  pharynx  becomes  involved  either  by  direct  extension  from  the 
larynx  and  epiglottis  or  from  the  lungs.  The  wall  of  the  pharynx  is 
often  closely  studded  with  tubercles  or  it  may  become  ulcerated,  and 
deglutition  is  then  extremely  painful.  The  disease  frequently  involves 
at  the  same  time  the  hard  or  soft  palate.  The  adenoids  of  the  naso- 
pharynx have  occasionally  been  found  tubercular. 

The  esophagus  is  seldom  involved  except  in  the  small  upper  segment 
as  a  result  of  direct  extension  from  the  pharynx  or  larynx.  Any  part 
of  it  may,  however,  become  infected  directly  from  the  bronchial  glands, 
the  vertebrae,  or  by  inoculation  from  the  sputum. 

T7ie  Sto77iach. — Tuberculosis  of  the  stomach  is  also  exceedingly  rare, 
probably  owing  to  the  protective  influence  of  the  acid  gastric  juice. 
But  single  or  multiple  tubercular  ulcers  are  occasionally  found  in  its 
mucous  membrane,  and  perforation  has  occurred  in  a  few  instances. 
The  symptoms  of  the  tubercular  ulcer  are  not  distinctive.  Intense  pain 
soon  after  eating,  vomiting,  especially  hematemesis,  are  usually  indic- 
ative of  it.  The  tuberculous  character  of  the  patient  should  arouse 
suspicion  of  the  tubercular  nature  of  the  disease. 

Tuberculosis  of  the  Intestine.— The  intestine  is  much  more  commonly 
the  seat  of  tuberculosis  than  the  upper  part  of  the  alimentary  canal. 
The  disease  is  primary,  however,  in  only  about  one  case  in  a  thousand 
adults.     It  is  a  little  more  frequent  in  children.    As  a  secondary  affection 


TUBERCULOSIS  207 

it  is  probably  most  frequently  a  result  of  the  swallowing  of  sputum, 
but  the  infection  may  be  conveyed  from  other  centers  through  the  blood 
or  lymph  circulation.  In  a  third  group  of  cases  it  results  from  the  direct 
extension  of  the  disease  from  the  peritoneum,  ovaries,  or  abdominal 
glands.  Secondary  involvement  of  the  intestine  occurs  in  nearly  half 
the  cases  of  pulmonary  tuberculosis,  usually  as  a  late  complication. 

Morbid  Anatomy. — The  lesions  are  remarkably  uniform  in  character. 
There  is  catarrhal  inflammation  of  the  mucosa,  with  hypertrophy  of  the 
villi,  and  later  more  or  less  extensive  ulceration.  The  primary  lesions 
are  often  situated  in  the  solitary  and  agminated  follicles.  These  become 
swollen  and  ulcerated  as  in  typhoid  fever,  but  the  ulcers  are  less  regular 
in  outline,  usually  have  a  caseous  base,  and  their  long  axes  soon  become 
transverse  to  that  of  the  intestine.  Little  chains  of  tubercles  extend  out- 
ward toward  the  mesentery,  sometimes  even  to  the  mesenteric  glands, 
and  the  ulceration  follows  their  course.  A  cluster  of  young  tubercles  is 
usually  found  in  the  serous  coat  immediately  opposite  the  ulcer  in  the 
mucosa.  The  ulcers  show  no  tendency  to  heal.  The  disease  is  generally 
situated  in  the  lower  part  of  the  ileum  and  cecum  and  upper  part  of 
the  colon.     A  large  area  of   the 


■iiJ^m^ijyyyj^iw 


bowel  is  often  involved,  but  in 
some  instances  it  is  confined  to 
a  limited  portion,  as  the  ileoce- 
cal region.  The  appendix  may 
also  become  involved.  Large 
tumor-like  masses  consisting  of 
the  intestine  and  caseous  nodules 
are  sometimes  formed  which  more 
or  less  completely  obliterate  the 
lumen.  Perforation  often  follows, 
leading  to  a  fatal  acute  peri- 
tonitis or  to  the  formation  of  a  Fig.  16.— Tubercular  ulcer  of  the  intestine, 
fecal  fistula.  Stenosis  from  cica-  ^^t  lii  """"^  ^"'^^'  ^'^""^^  °^  ^^^  War  of  the 
trization  is  a  less  frequent  result.         ^  ^  '°"'^ 

Fistula  in  ano  is  commonly  a  result  of  localized  tuberculosis  of  the 
rectum,  occasionally  primary  in  character. 

5//77yofo/77s.— Diarrhea  is  the  most  common  manifestation  of  intes- 
tinal tuberculosis.  The  stools  contain  much  mucus  and  often  pus  and 
blood.  The  bacilli  are  numerous  in  them,  but  they  cannot  be  regard- 
ed as  diagnostic  of  the  intestinal  lesion,  since  they  may  have  passed 
through  with  the  sputum.  Fever,  colicky  pains,  tenderness,  and  meteor- 
ism  are  usually  present.  The  emaciation  becomes  extreme.  But  the 
most  advanced  tubercular  lesions  are  sometimes  found  in  the  bowel 
after  death  in  cases  which  exhibited  no  evidence  of  intestinal  involve- 
ment during  life. 

Diagnosis. — The  diagnosis  of  primary  intestinal  tuberculosis  is  ex- 
tremely difficult.  The  persistent,  profuse  watery  dejections,  containing 
much  mucus  and  occasionally  pus  and  blood,  without  other  recognizable 
cause,  and  attended  with  abdominal  pain  and  tenderness,  especially  if 
the  pain  and  tenderness  be  confined  to  the  ileocecal  region,  are  sufficient 
to  arouse  suspicion'  of  the  disease.  The  presence  of  fever,  rapid  emacia- 
tion, and  the  discovery  of  bacilli  in  the  dejections  support  the  diagnosis, 


2o8  PRACTICE  OF  MEDICINE 

but  the  reaction  to  the  tuberculin  test  is  of  more  positive  value.  When 
a  tubercular  focus  can  be  recognized  elsewhere,  the  diagnosis  is  much 
less  difficult. 

Tuberculosis  of  the  Liver.— The  liver  is  always  involved  in  acute 
miliary  tuberculosis,  but  the  lesions  are  often  microscopic  in  size  and 
may  be  concealed  by  the  pale  color  due  to  fatty  degeneration.  Local- 
ized or  disseminated  tuberculosis  also  occurs.  In  the  former,  the  solitary 
large  tubercle  is  sometimes  found,  or  there  may  be  more  or  less  numer- 
ous smaller  nodules.  These  sometimes  undergo  softening  or  complete 
caseation  and  necrosis,  breaking  down  to  form  abscesses  which  may 
give  the  organ  a  honeycombed  appearance.  In  another  class  of  cases 
there  is  marked  sclerotic  increase  of  the  connective  tissue  accompanied, 
perhaps,  with  advanced  fatty  change.  The  nodular  formation  often  fol- 
lows the  course  of  the  bile-ducts.  Perihepatitis  is  sometimes  induced, 
with  the  production  of  ascites. 

Tuberculosis  of  the  Pancreas.— The  disease  is  always  secondary  in 
origin,  and  occurs  in  about  5  per  cent  of  all  cases  of  general  tubercu- 
losis in  children;  it  is  rare  in  adults.  Both  the  miliary  and  localized 
forms  are  encountered,  the  latter  sometimes  producing  large  abscess 
cavities.  The  infection  is  supposed  to  be  carried  either  through  the 
blood  or  lymph,  or  by  way  of  the  pancreatic  duct  from  the  intestine. 

The  splee?i  is  usually  involved  in  general  tuberculosis,  and  sometimes 
secondarily  in  chronic  pulmonary  tuberculosis.  The  foci  often  become 
caseous  and  abscesses  are  sometimes  formed. 

7.  TUBERCULOSIS  OF  THE  GENITOURINARY  SYSTEM. 

Tuberculosis  may  attack  any  part  of  this  system,  or  it  may  involve 
all  the  organs  simultaneously,  particularly  in  the  general  miliary  form 
of  the  disease.  It  is  comparatively  seldom  that  a  single  organ  or  viscus 
is  affected.  Probably  the  most  frequent  location  of  the  primary  lesion 
is  the  epididymis;  but  it  is  occasionally  found  in  the  testicle  proper. 
The  extension  of  the  disease  from  one  center  to  another  is  accomplished 
by  various  routes.  The  bacilli  readily  pass  downward  from  the  kidneys 
and  probably  upward  through  the  urethra  to  the  bladder,  in  the  same 
manner  as  they  pass  through  the  vagina  ;and  uterus  to  the  Fallopian 
tubes.  They  are  sometimes  conveyed  through  the  blood  from  the  lungs  or 
other  remote  centers  of  infection,  probably  also  by  the  lymph-vessels 
in  some  instances.  The  disease  may  extend  directly  from  the  intestine 
or  peritoneum  to  the'  bladder,  vesiculae  seminales  or  Fallopian  tubes, 
or  from  the  bodies  of  the  vertebrae  to  the  kidneys.  Infection  through 
sexual  intercourse  is  regarded  as  possible.  Genitourinary  involvement 
has  been  found  also  in  the  fetus,  illustrating  the  possibility  of  hereditary 
transmission.  The  disease  is  three  times  more  common  in  men  than  in 
women,  and  it  usually  develops  between  the  ages  of  20  and  40.  Its 
progress  from  region  to  region  is  generally  remarkably  rapid.  The 
extension  may  be  direct,  as  when  it  extends  by  the  formation  of  a  line 
of  tubercles  through  the  ureter  from  the  kidney  to  the  bladder,  and 
surface  inoculation  is  supposed  to  occur  in  some  instances.  Whether 
or  not  the  bacilli  ever  pass  upward  from  the  bladder  to  the  kidney  is 
an  unsettled  question,  as  it  is  thought  improbable  that  they  could  be 
carried  against  the  constant  flow  of  urine  through  the  ureter. 


TUBERCULOSIS  209 

Tuberculosis  of  the  Kidneys. — The  disease  may  be  primary,  but  it  is 
much  more  frequently  secondary  to  tuberculosis  of  other  organs.  One 
or  both  kidneys  may  be  affected.  Men  are  more  frequently  affected 
than  women,  and  generally  in  middle  life,  except  by  the  miliary  form, 
which  may  occur  in  any  age.  The  kidneys  are  involved  in  about  half 
the  cases  of  genitourinary  tuberculosis. 

Morbid  Anatomy. — In  general  miliary  tuberculosis,  miliary  tubercles 
are  found  scattered  throughout  the  organ  and  beneath  the  capsule, 
while  in  other  cases  they  are  often  confined  to  the  pelvis  and  papillae, 
producing  pyelitis.  It  sometimes  happens  after  death  from  pulmonary 
tuberculosis,  that  a  few  tubercles  are  found  in  the  kidneys,  which  had 
produced  no  recognizable  disturbance  during  life.  As  a  rule,  the  upper 
extremity  of  the  ureter,  and  in  more  chronic  cases  the  lower  portion  of 
it  and  perhaps  the  bladder  and  prostate,  are  involved  along  with  the 
pelvis  of  the  kidney.  In  quite  a  large  group  of  cases  the  testicles  are 
likewise  affected.  As  a  result  of  caseation  and  softening,  cyst-formation 
or  p}^onephrosis  is  induced.  By  the  coalescence  of  several  nodules,  large 
caseous  masses  are  formed.  One  kidney  is  often  found  in  a  more  ad- 
vanced stage  of  the  disease  than  the  other. 

Symptoms. — In  acute  miliary  tuberculosis  the  involvement  of  the  kid- 
ney seldom  attracts  attention.  In  the  chronic  form,  indeed,  there  may 
be  few  symptoms  until  a  late  stage  has  been  reached.  Advanced  lesions 
have  been  found  post  mortem  which  were  not  suspected  during  life. 
The  manifestations  are  then  characteristic  of  pyelitis.  When  the  kidney 
is  much  distended  by  tubercular  formations,  as  in  pyonephrosis,  there 
are  usually  constant  pain  and  tenderness  in  the  region.  The  pain  may 
become  agonizing  at  times,  but  in  other  cases  it  is  never  severe.  In 
some  cases  there  is  a  tumor-like  prominence  over  the  region  of  the 
affected  organ  and  fluctuation  may  be  detected.  There  may  be  also 
pain  in  the  bladder.  Micturition  becomes  frequent,  and  the  urine,  gen- 
erally of  acid  reaction,  often  contains  pus  and  blood.  Albumin  is  never 
absent,  and,  in  addition  to  pus-cells,  epithelium,  sometimes  caseous  masses, 
and  bacilli  are  found  in  it.  Casts  cannot  usually  be  recognized.  Irregu- 
lar fever  and  occasional  chills  are  often  observed.  The  constitutional 
symptoms  are  naturally  more  pronounced  when  both  kidneys  are  in- 
volved. The  intermittency  of  the  manifestations  is  strongly  character- 
istic. In  most  cases,  even  when  advanced,  there  are  intervals  of  freedom 
from  fever,  pain,  and  swelling,  with  secretion  of  clear  urine,  sometimes 
lasting  for  several  days  or  weeks,  followed  by  a  return  of  the  symptoms. 
In  this  manner  the  disease  may  run  along  for  several  years  without 
greatly  reducing  the  patient's  strength,  but  emaciation  is  generally 
progressive.  In  a  fev/  cases  old  caseated  or  calcified  masses  have  been 
found  in  the  kidneys  after  death  from  other  diseases,  indicating  that 
spontaneous  arrest  of  the  disease  had  occurred. 

Diagnosis. — The  persistency  and  intermittent  character  of  the  disease 
strongly  point  to  its  tubercular  nature,  but  in  most  cases  the  diagnosis 
is  difficult  unless  the  patient  be  submitted  to  the  tuberculin  test.  The 
discovery  of  tubercle  bacilli  in  the  urine  in  repeated  examinations  may 
be  regarded  as  proof  of  the  tubercular  character  of  the  lesions,  but  the 
smegma  bacillus  must  be  excluded.  Fortunately  this  may  readily  be 
done,  since  it  is  decolorized  by  immersion  for  a  minute  in  alcohol  after 

14 


2IO  PRACTICE  OF  MEDICINE 

staining  in  carbol-fuchsin.  But  the  tubercle  bacilli  are  not  generally 
discovered  in  more  than  half  the  cases.  It  is  usually  more  accurate 
to  examine  the  urine  that  has  been  withdrawn  by  the  catheter,  and  the 
precipitate  should  be  obtained  by  centrifugation.  Before  operation  is 
resorted  to,  the  urine  from  each  kidney  should  be  examined  separatel}-. 

Cystitis  can  generally  be  recognized  by  the  alkalinity  of  the  urine, 
the  greater  quantity  of  mucus,  and  the  less  frequent  appearance  of  blood, 
as  well  as  by  the  absence  of  tenderness,  pain,  or  swelling  in  the  region 
of  the  kidney. 

Cysts^  calculi,  and  tumors  of  the  kidney  can  generally  be  excluded  by 
the  presence  of  a  tuberculous  history  or  proof  of  such  infection  in  some 
other  organ.  Copious  hemorrhage  and  the  presence  of  a  large  tumor, 
although  possible  in  tuberculosis  of  the  kidney,  are  more  strongly  indica- 
tive of  pyelous  nephritis  or  malignant  disease.  The  latter  class  of  dis- 
eases shows  more  rapid  progress. 

Treatment. — The  general  treatment  of  the  tuberculous  condition  is 
highly  important  in  primary  genitourinary  cases,  in  order  to  favor  a 
spontaneous  arrest  of  the  disease.  The  urine  may  be  rendered  less 
irritating  and  the  pain  consequently  diminished  in  some  cases  by  admin- 
istration of  alkalis,  as  sodium  benzoate,  gr.  x  to  xv  (0.65  to  i.o),  well 
diluted,  every  four  hours,  or  urotropin,  gr.  v  to  x  (0.35 — 0.65),  thrice 
daily,  and  by  the  drinking  of  a  large  quantity  of  water. 

Tuberculosis  of  the  Ureter,  Bladder,  and  Urethra.— The  disease  is 
seldom  primary;  it  is  usually  an  extension  from  the  kidney.  In  the 
ureter  the  lesions  are  either  at  the  upper  extremity  or  they  are  confined 
to  a  small  area  just  above  the  vesical  extremity.  The  bladder  is  most 
frequently  infected  through  the  urine  from  the  diseased  kidney  or  from 
the  testicle,  seminal  vesicles,  or  prostate,  the  virus  probably  being 
carried  through  the  lymph-vessels.  The  disease  may  be  communicated, 
however,  by  direct  extension  from  the  peritoneum,  intestines.  Fallopian 
tubes,  ovaries,  or  vagina.  The  urethra  is  rarely  involved  and  probably, 
in  most  cases,  secondarily  to  one  or  more  of  the  associated  viscera. 

Symptoms.— The  symptoms  are  those  of  cystitis— frequent  mictu- 
rition, especially  at  night,  alkalinity  of  the  urine,  pus  being  generally 
present,  sometimes  with  hematuria.  Pain  in  the  penis,  especially  in  the 
glans,  is  often  complained  of,  and  it  is  sometimes  severe.  Vesical  tenes- 
mus often  occurs.  Tenderness  may  be  elicited  by  pressure  over  the  blad- 
der, or  by  rectal  examination.  Cystoscopic  examinations  may  reveal 
the  tubercles  beneath  the  mucous  membrane  at  an  early  period,  but 
later  large  or  small  ulcers  are  to  be  seen.  The  testes,  prostate,  and  other 
organs  should  always  be  examined  for  the  presence  of  tuberculosis  in 
them. 

Tuberculosis  of  the  Prostate.— The  prostate  may  become  involved  by 
extension  from  any  of  the  surrounding  viscera  in  the  manner  that  has 
been  described.  The  disease  is  generally  associated  with  that  of  the 
kidneys  or  bladder,  but  it  is  occasionally  primary  in  origin.  The  pros- 
tate seldom  escapes  when  the  testicle  and  seminal  vesicles  are  affected. 
There  is  often  a  history  of  previous  attacks  of  gonorrhea.  The  gland 
becomes  much  enlarged  from  the  growth  of  tubercular  nodules ;  caseous 
softening  often  leads  to  the  formation  of  an  abscess  with  many  sinuses,  or 
there  may  be  extensive  formation  of  new  fibrous  tissue.    The  irritabihty 


TUBERCULOSIS  211 

of  the  bladder  is  often  extreme,  with  painful  or  more  or  less  obstructed 
micturition,  and  catheterization  is  extremely  painful.  The  enlarged  lobes 
of  the  prostate  can  be  felt  upon  rectal  examination. 

Tuberculosis  of  the  Testicle.— The  disease  is  comparatively  frequent 
in  infants  and  young  children;  it  has  been  found  in  the  fetus,  and  it  is 
by  no  means  rare  in  the  adult.  It  appears  first  in  the  epididymis  of  the 
adult,  less  frequently  in  the  substance  of  the  testicle  or  in  the  vesiculse 
seminales.  It  is  generally  secondary  in  character.  One  or  both  testes 
may  be  involved.  The  growth  is  generally  rapid,  extension  from  one 
location  to  another  equally  so,  and  in  most  cases  the  seminiferous 
tubules  and  vas  deferens  soon  become  involved.  The  tubercles  may  be 
present  for  a  considerable  time  without  undergoing  caseation,  and  the 
appearance  often  suggests  sarcoma,  but  the  growth  is  less  rapid  than 
that  of  sarcoma.  The  testicle  is  usually  less  nodular  than  that  of  syphi- 
litic disease.  In  syphilis,  too,  the  vas  deferens  escapes,  and  the  swelling 
soon  becomes  free  from  pain.  The  therapeutic  test  should  be  employed 
in  obscure  cases.  Spontaneous  recovery  undoubtedly  occurs  in  rare 
instances,  but  the  disease  is  more  apt  to  become  generalized,  especially 
after  operation. 

Tuberculosis  of  the  epididymis  is  recognized  by  the  presence  of  painful 
and  sensitive  nodular  enlargement,  especially  at  the  head  of  the  loop. 

Tuberculosis  of  the  Female  Generative  Organs.— Tubercular  ulcers  of 
the  vulva  have  been  observed  in  a  very  few  instances.  The  disease  is 
not  uncommon  in  the  Fallopian  tubes,  but  it  is  comparatively  rare  in 
the  ovaries,  uterus,  and  vagina.  It  may  be  primary,  but  it  is  generally 
an  extension  from  other  centers  of  infection.  Tubercular  salpingitis  is 
recognized  by  a  characteristic  enlargement  of  the  tube  with  thickening" 
and  infiltration  of  the  walls;  caseous  masses  are  usually  found  in  the 
interior.  Both  tubes  are  ordinarily  affected.  The  tubercles  may  be 
recognizable  only  upon  microscopic  examination  of  the  specimen.  The 
fimbriae  are  generally  bound  down  by  adhesions  to  the  ovaries,  and  the 
disease  extends  in  most  cases  to  the  endometrium,  very  often  also  to 
the  peritoneum.     Large  abscess-cavities  are  sometimes  formed. 

Tuberculosis  of  the  ovary  is  always  secondary.  Extensive  caseation 
and  abscess-formation  are  its  chief  characteristics.  Primary  tuberculosis 
of  the  uterus  has  been  described,  but  the  disease  is  usually  associated 
with  pulmonary  or  other  involvement.  The  disease  generally  assumes 
the  form  of  ulcerative  endometritis,  with  an  accumulation  of  caseous 
and  purulent  debris  in  the  cavity.  The  muscular  substance  is  sometimes 
infiltrated.  Tubercular  disease  of  the  cervix  is  generally  a  result  of  in- 
fection from  the  vagina.  Communication  of  the  disease  by  sexual  con- 
tact is  supposed  to  be  possible. 

Tuberculosis  of  the  Mammary  Gland.— The  mammae  are  seldom 
aftected.  In  some  instances  the  disease  is  primary,  the  bacilli  reaching 
the  glands  through  the  blood  or  through  the  lactiferous  ducts,  while 
in  other  instances  it  originates  in  the  skin  and  afterward  extends  to 
the  gland.  It  has  been  seen  mostly  between  the  ages  of  40  and  60, 
and  only  once  or  twice  in  the  male.  Distinct  tubercular  nodules  are 
formed  which  tend  to  unite  and  form  large  caseous  masses.  The  disease 
usually  remains  localized  for  many  years.  The  axillary  glands  and  other 
regions  are  generally  simultaneously  involved  when  the  disease  is  not 


212  PRACTICE  OF  MEDICINE 

primar)^.  It  should  be  borne  in  mind  that  a  nontubercular  chronic  in- 
terstitial mammitis  sometimes  occurs  in  connection  with  pulmonary  tu- 
berculosis. 

Diagnosis    of    Tuberculosis. 

•The  early  recognition  of  tuberculosis  is  all-important.  The  discovery 
of  bacilli  in  the  tissues  or  discharges  from  a  diseased  area  establishes 
the  tuberculous  character  of  the  disease;  but  in  the  pulmonary  form, 
the  most  frequent,  most  serious,  and  therefore  most  important  of  all 
forms,  the  bacilli  do  not  appear  until  a  comparatively  advanced  stage 
has  been  reached.  The  absence  of  bacilli  signifies  nothing,  but  their 
presence  in  several  successive  examinations  is  proof  of  the  infection. 

The  Tuberculin  Test. — This  method  of  diagnosis  is  still  employed  by 
some  physicians  who  regard  it  as  both  safe  and  sure,  but  a  majority 
condemn  it.  There  can  be  no  doubt  that  in  many  instances  its  use 
lights  up  a  latent  process ;  the  slight  fever  of  reaction  is  continued  into 
a  fever  of  tuberculization,  and  the  diagnosis  is  confirmed  at  the  expense 
of  awakening  a  more  rapid  progress  of  the  disease.  The  reaction  is 
a  sufficient  demonstration  in  most  cases  of  the  existence  of  tuberculosis 
somewhere  in  the  body,  but  the  test  should  be  employed  with  the  utmost 
care  and  in  full  understanding  of  its  dangers.  It  is  highly  probable 
that  many  of  the  reported  unfavorable  results  have  arisen  from  the 
use  of  too  large  and  too  frequent  doses.  The  initial  dose,  given  hypo- 
dermically,  is  usually  0.5  to  i  mg.,  diluted  in  distilled  water.  This 
is  subsequently  increased  gradually  until  5  mg.  are  given  every  24 
or  48  hours.  The  reaction  occurs  in  most  cases  within  from  4  to  12 
hours  after  the  first  dose,  but  occasionally  not  until  several  injections 
have  been  given.  The  reaction  is  indicated  by  an  elevation  of  tempera- 
ture sometimes  reaching  101°  to  104°  F.  (^■Ty'&° — 40°  C),  with  headache, 
chilliness,  nausea,  sometimes  vomiting,  pain  in  the  limbs,  and  languor. 
There  is  also  a  marked  stimulation  of  local  tubercular  processes  wherever 
situated.  Tubercular  areas  in  the  skin,  glands,  and  joints,  for  example, 
become  swollen,  red,  painful  and  sensitive,  and  in  pulmonary  tuberculosis 
there  is  evidence  of  similar  action.  The  sputum  becomes  more  abundant 
and  contains  numerous  living  bacilli,  sometimes  also  caseous  fragments. 
Dead  caseous,  calcareous,  or  necrotic  tissues  are  not  acted  upon.  The 
value  of  the  test  is  modified,  however,  by  the  fact,  repeatedly  observed, 
that  it  sometimes  reacts  in  perfectly  healthy  persons  and  fails  in  those 
who  are  afterward  proved  to  ha.ve  been  tuberculous.  Of  the  two  tests, 
the  demonstration  of  bacilli  is  by  far  the  more  valuable. 

The  X-ray  has  been  employed  for  the  demonstration  of  tuberculosis. 
For  the  recognition  of  such  surgical  lesions  as  the  destruction  of  bone 
it  is  undoubtedly  useful.  It  will  also  reveal  large  areas  of  solidification 
in  the  lung;  but  in  the  early  stage,  when  the  revelation  is  of  the  most 
importance,  it  is  seldom  positive.  An  area  which  is  sufficiently  large 
to  be  recognizable  by  this  means  is  almost  always  readily  recognizable 
by  the  ordinary  methods  of  percussion  and  auscultation. 

A  careful  study  of  the  symptomatology  of  the  disease  and  of  the 
physical  signs  enables  the  physician  to  recognize  the  disease  in  a  great 
majority  of  cases  without  other  aid.  The  examination  of  the  sputum, 
however,  ought  never  to  be  neglected,  since  it  is  the  most  positive  means 


TUBERCULOSIS  213 

of  difterentiating  most  of  the  other  diseases  which  may  be  confounded 
with  tuberculosis — notably,  bronchiectasis,  chronic  interstitial  pneumo- 
nia, syphilis,  and  malignant  disease  of  the  lung. 

Bronchiectasis. — In  this  condition  cavities  are  formed  and  there  is  an 
exceedingly  copious,  often  fetid,  purulent  expectoration,  particularly  in 
the  morning.  The  diagnosis  rests  for  the  most  part  upon  the  absence 
of  bacilli.  But  bronchiectasis  is  probably  in  most  instances  a  part  of 
the  tubercular  process  in  the  lungs. 

Chronic  Interstitial  Ptieiononia. — In  this  disease  there  is  usually  a  his- 
tory of  long-standing  bronchitis,  a  previous  attack  of  pneumonia,  bron- 
chopneumonia, chronic  pleuris}^,  or  a  pneumonokoniosis.  There  may 
be  a  marked  deformity  of  the  chest,  dyspnea,  cough,  and  free  expec- 
toration. The  patient  has  a  dull,  heavy  expression,  with  thick  lips 
and  dusky  complexion.  Percussion  and  auscultation  reveal  a  general, 
or  quite  extensive,  involvement  of  the  lungs.  The  general  condition  of 
the  patient  is  often  better  than  would  be  compatible  with  tubercular 
disease.  Anemia,  emaciation,  and  debility  are  not  marked,  and  there  is 
no  fever.  In  some  cases,  however,  the  diseases  are  associated  in  the 
same  subject. 

Syphilis  of  the  Lung. — The  history  of  the  patient,  if  obtainable,  and  the 
absence  of  bacilli  should  point  to  the  possibility  of  syphilis.  Syphilitic  le- 
sions are  seldom  found  in  the  apex,  more  frequently  down  near  the  roots 
of  the  lung.  They  are  not  usuaily  accompanied  by  so  profound  emacia- 
tion, and  the  anemia  may  be  less  marked.  In  some  cases  the  diagnosis 
must  rest  until  the  effect  of  antisyphilitic  treatment  has  been  tried. 

MaligJiant  Disease. — Sarcoma  and  carcinoma  both  affect  the  lung  sec- 
ondarily, the  former  following  possibly  remote  disease  in  the  line  of  ve- 
nous communication,  the  latter  a  less  distant  growth,  connected  by 
the  lymph-vessels.  Or  there  may  be  the  history  of  a  recently  removed 
tumor.  More  than  one  area  of  dullness  is  usually  found,  corresponding 
to  an  equal  number  of  tumors.  The  progress  of  the  disease  is  rapid 
and  generally  febrile.    Tubercle  bacilli  are  not  to  be  found. 

Finally,  such  conditions  as  anemia,  heart  disease,  gastritis,  and  ne- 
phritis are  to  be  excluded  only  by  careful  examination,  with  full  appre- 
ciation of  the  blood-changes  and  the  gastric,  cardiac,  and  renal  disturb- 
ances which  commonly  attend  tuberculosis  at  one  or  another  stage. 

Phthisiophobia. — Cases  are  by  no  means  uncommon  in  which  there  is 
a  hypochondriacal  dread  of  tuberculosis.  Cough,  thoracic  pains,  and 
great  weakness  are  the  usual  complaints,  but  there  is  entire  absence 
of  the  physical  signs,  and  the  psychical  state  of  the  individual  stamps 
itself  upon  every  symptom. 

Prognosis  of  Tuberculosis. 

There  are  no  fast  rules  by  which  to  estimate  the  prospects  of  a  given 
case.  Much  depends  upon  the  location  of  the  disease,  its  extent,  its 
virulence,  the  patient's  power  of  resistance,  and  the  measures  taken  to 
arrest  the  disease.  The  prognosis  is  always  more  unfavorable  in  a  case 
that  has  pursued  an  active  course.  A  tuberculous  tendenc}^  decreases 
resistance.  A  good  appetite  and  vigorous  digestion,  added  to  previous 
good  health  and  an  absence  of  depressing  influences,  increase  the  chance 


214  PRACTICE  OF  MEDICINE 

of  recovery — but  it  is  always  a  chance;  a  majority  of  the  cases  of  sup- 
posed recovery  relapse  sooner  or  later,  and  the  apparent  cure  proves 
to  have  been  but  a  quiescent  period.  A  slow,  afebrile  beginning,  with 
pleurisy,  is  generally  followed  by  a  protracted  course.  The  most  un- 
favorable symptoms  are  persistent  fever,  pronounced  anemia,  especially 
chlorosis,  loss  of  appetite,  and  feeble  digestion.  The  number  of  bacilli 
found  in  the  sputum  is  of  little  importance  in  prognosis,  for  they  may 
originate  in  a  small  focus  and  they  may  continue  for  months  after 
arrest  of  the  process.  Repeated  hemoptysis  is  usually  unfavorable. 
The  same  is  true  of  night-sweats,  persistent  diarrhea,  and  progressive 
loss  of  weight.  The  development  of  acute  pneumonia  of  any  type  often 
converts  a  quiescent  case  into  a  rapidly  fatal  one. 

Marriage  during  the  existence  of  active  tuberculosis  is  always  harm- 
ful, and  especially  to  the  woman,  since  pregnancy  and  lactation  greatly 
hasten  the  progress  of  the  disease.  Marriage  after  recovery  from  tuber- 
culosis has  often  resulted  happily.  Such  persons  should  be  taught  the 
necessity  of  giving  their  offspring  all  possible  benefit  of  nutritious  food, 
outdoor  life,  and  judicious  gymnastic  training.  Advice  against  marriage 
is  seldom  gratefully  received  and  rarely  heeded. 

Prophylaxis  of  Tuberculosis. 

The  enormous  numbers  of  bacilli  which  a  tuberculous  patient  is 
capable  of  throwing  off  daily  has  been  referred  to.'  The  importance  of 
measures  for  the  prevention  of  contagion  is  apparent.  It  is  the  duty 
of  physicians  everywhere  to  cooperate  with  and  to  assist  the  boards 
of  health  in  all  proper  efforts  to  this  end.  Political  and  professional 
prejudices  should  be  forgotten  in  matters  affecting  public  health.  The 
reporting  of  cases  of  tuberculosis  is  required  by  law  in  most  of  our 
cities,  but  in  too  many  places  the  matter  ends  with  the  filing  of  the 
report.  In  other  places  a  list  of  instructions  in  the  nature  of  the  disease 
and  the  measures  to  be  taken  for  the  protection  of  others  is  sent  to 
the  patient  through  his  physician.  The  list  should  contain  directions 
for  the  collection  and  destruction  of  sputum  and  emphatic  warning 
against  promiscuous  spitting  in  public  places  and  conveyances.  The 
use  of  the  "spit-cup,"  or  of  a  china  cuspidor  always  half-filled  with  a 
solution  of  corrosive  sublimate,  i  1500  or  stronger,  should  be  insisted 
upon.  The  patient  should  be  cautioned  against  the  danger  in  swal- 
lowing the  sputum.  He  should  occupy  a  room  separate  from  the  apart- 
ments of  his  family,  one  receiving  a  large  supply  of  sunlight  and  air. 
Flies  should  be  excluded  from  it,  for  they  are  carriers  of  bacilli.  The 
bedclothing  should  be  exposed  for  several  hours  each  day  to  the  air 
and  sunshine.  Occasional  disinfection  of  the  room  and  its  contents 
with  formaldehyd  is  beneficial.  The  irritating  fumes  of  the  disinfectant 
can  be  removed  by  sprinkling  a  little  aqua  ammonia  about  the  room. 
When  these  requirements  cannot  be  carried  out,  it  is  better  to  have  the 
patient  removed  to  a  sanitarium,  where  he  will  be  placed  under  strict 
rules  both  for  his  own  treatment  and  for  the  protection  of  others. 

The  inspection  and  regulation  of  the  milk  and  meat  supplies  are  also 
of  importance  to  the  public.  Much  good  has  unquestionably  been  done 
in  late  years  by  the  agitation  against  filthy  dairies  and  by  the  sys- 
tematic inspection  of  milk,  cows,  and  market  meat. 


TUBERCULOSIS  215 

Individual  Prophylaxis. — This  should  begin  at  the  time  of  a  child's 
birth.  The  infant  should  not  be  nursed  by  its  tuberculous  mother. 
If  a  wet-nurse  is  not  obtainable,  the  greatest  care  should  be  exercised 
in  the  selection  of  an  artificial  food.  A  modification  of  fresh  cow's  milk 
is  better  than  a  substitute,  and  milk  should  constitute  a  large  part  of 
the  child's  diet  during  the  whole  of  childhood.  The  clothing  should  be 
carefully  adapted  to  the  changes  of  the  weather.  Light  flannel  garments 
of  open  texture  should  be  worn.  Such  children  should  be  kept  as  much 
as  possible  in  the  open  air.  They  should  be  early  started  in  a  course  of 
gymnastics  directed  especially  to  the  development  of  the  respiratory 
muscles,  and  athletic  sports  should  be  encouraged.  They  should  be 
taught  to  bathe  daily  in  cool  water.  Cold  sponging  of  the  throat  and 
chest  morning  and  evening,  or,  better,  of  the  entire  body  at  least  once 
a  day,  has  a  decided  effect  in  warding  off  "  colds."  Especially  important 
is  the  ventilation  of  the  bedroom  at  night.  The  windows  should  never 
be  closed;  the  more  nearly  the  air  in  the  sleeping  apartment  can  be 
made  to  correspond  to  that  of  the  outside,  the  better.  The  greatest 
care  should  be  exercised  to  avoid  catarrhal  affections.  The  nose  and 
throat  should  be  frequently  examined  with  reference  to  catarrh,  the 
presence  of  adenoids,  and  hypertrophied  tonsils;  and  it  is  important 
that  complete  recovery  be  secured  after  the  acute  infections  of  childhood. 
The  resulting  anemic  condition  should  be  as  speedily  as  possible  over- 
come by  the  administration  of  iron,  arsenic,  and  codliver  oil  or  malt. 
Young  persons  having  tuberculous  tendencies  should  reside  in  the  health- 
ful climates  of  the  West  rather  than  attempt  to  combat  the  disease 
against  the  odds  imposed  by  the  long,  severe  winters  of  the  Northern 
and  Eastern  States. 

Treaimeni  of  Tuberculosis. 

The  treatment  of  tuberculosis  resolves  itself  into  the  cure  (care) 
of  the  patient,  rather  than  the  adoption  of  measures  for  the  destruc- 
tion of  the  bacillus,  for  in  attaining  the  former  end  we  do  more  than 
is  possible  by  any  other  means  toward  the  accomplishment  of  the 
latter.  The  biological  processes  of  the  body,  properly  supported,  are 
capable  of  overcoming  the  infection  in  probably  a  majority  of  cases. 
For  their  support  the  best  measures  are  secured  by  the  regulation  of 
the  patient's  habits  and  mode  of  life,  his  food  and  all  that  contributes 
to  an  increase  of  nutrition.  The  earlier  these  measures  can  be  adopted, 
the  greater  will  be  the  chances  of  success.  Unfortunately  many  cases 
that  the  physician  encounters  have  been  neglected  until  all  prospect  of 
recovery  has  vanished. 

When  a  case  is  seen  in  its  incipiency,  a  complete  change  in  the  life  of 
the  individual  should  generally  be  made.  More  hours  should  be  given  to 
leisure,  more  hours  spent  in  the  open  air.  All  employment  would  better 
be  given  up,  if  possible,  and  the  first  winter,  at  least,  should  be  spent 
in  a  warm  climate  where  the  patient  can  remain  in  the  open  air  day 
and  night.  He  should  not  return  north  before  the  month  of  May.  Per- 
manent removal  to  a  suitable  climate  is  of  course  to  be  recommended. 
But  a  majority  of  persons  are  not  so  situated  as  to  make  such  changes 
without  undergoing  hardships  more  than  equivalent  to  the  benefit  to 
be  derived.    These  must  be  treated  at  home.    If  they  reside  in  a  large 


2i6  ,  PRACTICE  OF  MEDICINE 

city,  removal  to  the  suburbs  is  advisable,  and  the  farther  out  the  better. 
The  patient  should  be  taught  to  practice  respiratory  gymnastics,  deep 
breathing  in  the  open  air  or  at  an  open  window  several  times  a  day 
for  many  minutes  at  a  time,  and  to  strengthen  the  respiratory  muscles 
by  the  use  of  light  dumbbells  and  "pulleys."  There  is  no  better  exercise 
for  the  breathing  than  rapid  walking  or  moderate  running  in  the  open 
air,  providing  it  does  not  cause  an  elevation  of  temperature,  and  the 
distance  may  be  increased  a  little  each  day.  Exercise  should  never  be 
carried  to  the  point  of  fatigue.  The  patient  should  take  a  rapid  cold 
sponge  bath  every  morning.  It  should  be  taken  in  a  warm  room,  the 
patient  standing  upon  a  rug,  not  in  the  tub.  If  strong  enough,  he  should 
rub  his  own  body.  After  the  bath  the  skin  should  be  rubbed  into  a  glow 
with  a  crash  towel.  This  may  be  followed  by  a  rapid  sponging  with  di- 
lute alcohol.  After  breakfast,  whenever  the  weather  will  permit,  the  pa- 
tient should  take  a  walk  in  the  open  air.  A  daily  sun-bath  should  be 
taken  when  possible,  summer  and  winter,  the  entire  body  being  exposed 
to  the  rays  of  the  sun  in  a  solarium  or  at  an  open  window.  If  this 
cannot  be  done,  the  patient  should  sit  in  the  sunshine  for  several  hours ; 
even  in  bad  weather  he  should  sit  in  the  open  air  on  a  veranda.  These 
measures  must,  of  course,  be  undertaken  gradually  at  first. 

If  the  patient  is  too  ill  to  leave  his  room,  he  should  still  be  given 
all  possible  advanta,ge  of  the  air  and  sunlight. 

Dietetic  Treatment. — One  of  the  most  favorable  results  of  a  change  to 
outdoor  life  is  often  seen  in  the  stimulation  of  the  appetite.  The  food 
should  be  of  the  most  nutritious  kind  and  should  contain  as  much  fat 
as  the  system  can  assimilate.  Food  should  generally  be  given  at  shorter 
intervals  than  in  health,  the  regular  meals  being  supplemented  by  a 
light  lunch  in  the  middle  of  the  forenoon  and  afternoon  and  before  re- 
tiring. A  glass  of  rich  milk  may  be  taken  during  the  night.  A  half- 
dozen  or  more  eggs,  soft-boiled,  poached,  or  raw  with  sherry,  may  be 
taken  daily,  if  digestion  is  good.  There  is  no  better  form  of  fat  than 
cream  or  butter.  Nitrogenous  food,  as  a  rule,  agrees  better  with  the 
patient  and  enables  him  better  to  combat  the  disease.  If  the  theory 
that  uric  acid  in  the  blood  antagonizes  the  tubercle  bacillus  be  true, 
there  is  no  better  way  of  securing  this  condition  of  the  blood  than  by 
the  exclusive  meat  diet,  or  a  near  approach  to  it. 

In  many  cases  the  digestive  processes  appear  slow.  The  ingestion 
of  a  full  meal  arrests  appetite  for  an  entire  day,  and  the  bowels  are 
usually  constipated.  In  such  cases  digestive  ferments  may  be  given 
with  advantage;  in  some  cases  pepsin,  in  others  a  diastase  and  malt 
extract.  The  occasional  administration  of  i-io  gr.  (0.006)  of  calomel 
for  a  few  days  often  aids  the  digestion.  The  existence  of  fever  does  not 
contraindicate  a  liberal  diet.  When,  however,  filling  the  stomach  induces 
coughing,  and  this  in  turn  vomiting,  a  liquid  diet  should  be  taken  in 
small  quantities  at  intervals  of  two  or  three  hours.  Beef,  chicken,  or 
other  broths  may  be  added  to  the  list.  In  some  cases  forced  feeding 
must  be  practiced.  As  much  as  a  quart  of  liquid  food,  chiefly  milk,  is 
introduced  into  the  stomach  two  or  three  times  a  day  by  means  of  a 
tube.  The  method  is  applicable  especially  to  cases  in  which  there  is  a 
great  aversion  to  food,  or  in  which  there  is  so  great  destruction  of  the 
epiglottis  as  to  render  deglutition  impossible. 


TUBERCULOSIS  217 

Climatic  Treat?}ient — The  selection  of  a  suitable  climate  depends  largely 
upon  the  condition  of  the  patient  and  the  stage  of  the  disease.  Ad- 
vanced cases  do  better  at  home.  They  rarely  receive  benefit  from  a 
change  of  climate  that  compensates  them  for  the  hardships  of  travel. 
Poor  people  in  any  stage  are  generally  better  at  home.  Some  cases 
show  greater  improvement  in  a  high,  dry  atmosphere,  while  others 
improve  in  the  pure  damp  air  of  the  seashore.  Cases  that  have  ad- 
vanced to  cavity -formation-  and  those  accompanied  with  repeated  hemor- 
rhages should,  as  a  rule,  seek  a  warm  equable  climate  of  low  altitude, 
as  in  the  resorts  of  Georgia,  South  Carolina,  and  the  east  coast  of 
Florida,  Bermuda,  or  southern  California.  These  places  are  also  better 
for  persons  who  are  compelled  to  return  north  in  the  summer.  Many 
advanced  cases  have  made  remarkable  improvement  in  Colorado,  New 
Mexico,  x-lrizona,  and  other  Western  States,  but,  as  a  rule,  a  return  to  a 
place  of  low  altitude  causes  an  awakening  of  the  disease,  so  sharp  that 
a  return  to  the  high  altitude  proves  of  no  benefit.  Many  patients  and 
some  physicians  fall  into,  the  error  of  assuming  that  climate  alone  can. 
effect  a  cure.  It  is  only  when  a  change  of  climate  is  supplemented  by 
home  comforts,  with  an  abundance  of  proper  food,  that  great  benefit 
can  be  expected  from  it,  and  the  measures  which  prove  of  advantage  in 
home  treatment  are  all  the  more  efficient  when  aided  by  the  pure,  ex- 
hilarating atmosphere  of  Colorado.  It  is  not  generally  advisable  to 
send  a  patient  to  a  place  where  he  is  an  entire  stranger,  without  a  com- 
panion, unless  he  has  been  accustomed  to  travel,  for  the  homesickness, 
is  often  worse  than  the  disease. 

General  Medical  Treatment. — No  drug  has  yet  been  discovered  which  is. 
capable  of  acting  directly  upon  the  tubercular  process.  The  few  remedies 
which  deserve  mention  act  solely  by  improving  the  condition  of  the 
patient,  by  stimulating  his  nervous  system,  enriching  his  blood,  and 
thus  increasing  his  power  of  resistance,  or  possibly  by  rendering  the  tis- 
sues less  susceptible  to  invasion.  The  principal  remedies  are  creosot, 
iron,  arsenic,  strychnin,  hypophosphites,  and  codliver  oil. 

Creosot. — This  remedy  has  outlived  a  thousand  in  the  estimation  of  the 
profession,  although  it  is  recognized  as  having  no  specific  action  on  the 
disease.  In  many  cases  it  quiets  the  cough,  diminishes  the  expectoration, 
increases  the  appetite  and  digestion.  It  may  be  taken  in  milk,  sherry,  hot 
water  flavored  with  an  essential  oil,  as  cinnamon  or  cloves,  or  in  capsules. 
The  dose  should  not  exceed  Tr[j  to  ij  (0.06 — 0.12)  after  each  meal,  in  the 
beginning,  but  it  may  be  increased  one  drop  a  day  until  Tll.x  to  xx  (0.60 
— 1.25)  are  taken,  providing  that  the  stomach  continues  to  tolerate  it. 
Only  a  pure  creosot,  made  from  beechwood  tar,  should  be  administered. 
This  remedy  has  been  employed  also  for  inhalation,  for  subcutaneous, 
intratracheal,  or  intrapulmonary  injection  and  by  the  rectum. 

Some  clinicians  prefer  guaiacol  to  creosot.  It  is  especially  suitable 
for  administration  to  children  by  inunction.  It  may  be  given  hypoder- 
mically  in  oil.  It  is  often  not  so  well  tolerated  by  the  stomach.  When 
neither  of  these  remedies  can  be  taken  by  the  mouth,  their  carbonates 
should  be  employed.  The  best  time  for  administration  is  probably 
two  hours  after  each  meal.  In  intestinal  tuberculosis  the  creosot  acts 
well  when  given  in  keratin  capsules,  which  do  not  dissolve  until  they 
reach  the  intestine. 


2i8  PRACTICE  OF  MEDICINE 

Iron. — This  remedy  is  useful  only  for  the  relief  of  the  anemia  and  es- 
pecially in  children.  The  sirup  of  the  iodid  is  the  best  remedy  for  the 
tuberculous  adenitis.  In  chlorotic  anemia,  Blaud's  pills,  gr.  iij  (0.2),  or 
the  tincture  of  the  chlorid,  tT[x  (0.60),  should  be  employed. 

Arsenic. — This  is,  as  a  rule,  the  best  remedy  for  the  anemia,  acting 
more  promptly  and  more  certainly  than  iron.  Three  to  live  drops  of 
Fowler's  solution  are  given  after  each  meal.  The  dose  may  be  gradually 
increased  until  the  effect  is  recognizable,  but  large  doses  are  not  gener- 
ally required. 

Strychnin  is  useful  as  a  general  tonic,  but  it  is  especiall}^  indicated 
when  the  heart's  action  becomes  irregular  or  weak.  A  dose  immediateh^ 
upon  awaking  often  gives  the  patient  strength  to  take  his  morning's 
bath.  It  should  be  given  in  doses  of  gr.  1-60  to  1-20  (o.ooi — 0.003).  It 
may  be  combined  with  iron  and  arsenic  or  given  in  tablet  form. 

Hypophosphites. — The  hypophosphites  of  Ume  and  soda  are  believed 
by  some  physicians  to  exert  a  tonic  influence  and  to  reduce  the  expec- 
toration.    They  probably  have  no  other  action. 

Codliver  oil  has  in  some  cases  a  decided  influence  in  increasing  the 
nutrition  and  in  relieving  cough.  It  acts  best  in  children  and  in  the 
incipient  stage.  Some  physicians  prefer  the  pure  oil,  others  an  emulsion. 
The  dose  should  not  be  too  large  and  can  best  be  regulated  b}^  its 
effects  upon  the  appetite.  From  a  teaspoonful  to  a  tablespoonful  two 
hours  after  meals  is  the  quantity  usually  administered.  \Mienever  the 
appetite  fails,  the  dose  should  be  reduced.  In  the  advanced  stages  it  is 
of  no  benefit,  and  when  diarrhea  or  fever  is  present  or  digestion  is  feeble 
it  is  contraindicated. 

Urea. — The  fact  that  tuberculosis  and  gout  are  seldom  associated  in 
the  same  individual  or  family  led  Henry  Harper  and  others  to  admin- 
ister pure  urea  in  doses  of  gr.  xx  (1.30)  or  more  four  times  a  day. 
Excellent  results  were  reported  from  the  treatment,  especially  when  it 
was  combined  with  a  diet  favoring  the  production  and  retention  of 
uric  acid  in  the  system,  but  the  investigations  of  Pearson  indicate  that 
it  is  of  little  benefit  in  tuberculosis  of  the  lungs.  Its  action  is  more 
certain  in  tuberculosis  of  the  joints. 

Treatment  of  Special  Symptoms. — Fever.— There  is  probably  no  other 
type  of  fever  which  is  so  diiificult  of  control  as  that  of  tuberculosis. 
The  coal-tar  antipyretics  control  the  temperature  only  temporarih^, 
and  their  depressing  eftect  is  undesirable.  Quinin  cannot  usuall}-  be 
taken  in  sufficient  doses  to  be  of  benefit  without  deranging  the  digestion. 
In  most  cases  more  can  be  accomplished  by  rest  in  the  open  air  and  by 
cool  bathing  and  sponging  than  with  drugs.  Osier  speaks  favorably, 
however,  of  2-gr.  (0.13)  doses  of  antifebrin  every  hour  for  three  or 
four  hours  before  the  rise  of  temperature  takes  place. 

Sweating. — The  aromatic  sulphuric  acid,  TT[xx — xxx(i.2  5 — i.8o)t. i. d., 
often  arrests  sweating  in  the  early  stages.  Later,  atropin,  gr.  i-ioo 
(0.0006)  morning  and  evening  or  gr.  1-60  (o.ooi)  at  bedtime,  is 
more  effective  for  night-sweats.  Other  remedies  are  :  agaricin,  gr.  1-6 
(o.oi),  muscarin  (i  per  cent  solution)  TTlv  (0.30),  and  picrotoxin,  gr. 
1-60  (o.ooi). 

Cough. — \Vhen  the  cough  is  not  so  severe  as  to  interfere  with  sleep 
it  serves  a  useful  purpose  and  should  be  let  alone.    In  the  distressing 


TUBERCULOSIS  219 

night-cough,  however,  it  is  necessary  to  administer  remedies  for  its 
rehef.  In  many  cases,  heroin,  gr.  1-12  (0.0056),  taken  before  retiring, 
is  sufficient  for  the  night;  but  in  other  cases  it  fails.  It  is  then  better 
to  give:  Dover's  powder,  gr.  ij  to  v  (0.13 — 0.32);  codein,  gr.  ^  to  ^ 
(0.008 — 0.016);  or  morphin,  gr.  1-16  to  y^  (0.004 — 0.008).  When  the 
cough  is  dry,  the  morphin  may  be  given  in  a  mixture  of  which  each  dose 
contains  also  the  dilute  hydrocyanic  acid,  ill,ijtoiij(o.i  2 — 0.18),  or  cherry- 
laurel  water,  3  ss  (1.80).  In  all  cases  of  persistent  cough,  the  posterior 
nares,  pharynx,  and  larynx  should  be  examined,  for  it  will  often  be  found 
that  a  small  fissure,  granulation,  or  ulcer  is  the  principal  cause  of  the 
cough,  and  that  a  few  applications  of  silver  nitrate  give  the  most  grati- 
fying relief.  Inhalations  of  creosot,  benzoin,  or  tar,  or  spraying  the 
throat  just  before  retiring  with  a  strong  (5 — 10  per  cent)  solution  of 
menthol,  often  prevents  the  cough  for  several  hours,  and  it  may  be 
repeated  during  the  night.  xA^n  elongated  or  congested  uvula  is  an  oc- 
casional cause  of  persistent  cough. 

Appetite. — The  appetite  is  often  much  improved  by  the  administration 
of  the  bitter  tonics,  especially  the  compound  tincture  of  gentian,  3  j  to  ij 
(3.75 — 7.50),  shortly  before  meals.  Moderate  exercise  in  the  open  air 
is  often  sufficient. 

Diarrhea. — In  the  early  stages  of  the  disease,  diarrhea  can  usually  be 
arrested  with  large  doses  of  bismuth  and  regulation  of  the  diet.  Later, 
opium  and  astringents  are  generally  required.  The  lead  and  opium  pill, 
gr.  iij  to  v  (0.20 — 0.30),  or  gallic  acid,  gr.  iij  to  x  (0.20 — 0.65),  may  be 
employed.  Salol,  thymol,  naphthol,  and  other  intestinal  antiseptics  are 
also  employed.  It  is  sometimes  necessary  to  reduce  temporarily  the 
quantity  of  fat  taken  by  the  patient  or  to  restrict  his  diet  to  milk.  If 
the  intestine  has  become  tubercular,  however,  it  is  useless  to  temporize, 
and  morphin  should  be  given  at  short  intervals  in  sufficient  doses  to 
hold  the  diarrhea  within  bounds;  it  cannot  be  entirely  overcome. 

Hemoptysis. — The  patient  should  be  immediately  placed  in  a  recumbent 
posture  and  kept  absolutely  quiet.  He  should  not  be  asked  questions 
or  permitted  to  speak.  Morphin,  gr.  i^^  (0.0016),  should  be  administered 
hypodermically,  and  an  ice-bag  should  be  placed  upon  the  chest,  over 
the  point  at  which  the  bleeding  is  going  on.  When  the  pulse  is  full  and 
bounding,  it  may  be  reduced  by  the  cautious  administration  of  aconite. 
One-half  minim  (0.03)  doses  of  the  fluid  extract  may  be  given  every 
half-hour  for  perhaps  two  or  three  hours,  but  only  until  the  effect  be- 
comes apparent.  The  most  important  point  in  the  treatment,  however, 
is  to  keep  the  lung  at  rest,  and  this  can  be  done  by  the  administration 
of  an  opiate  in  sufficient  doses  to  keep  the  patient  in  a  quiet  sleep  for 
24  to  48  hours.  WTien  a  large  quantity  of  blood  has  been  lost,  the  saline 
infusion  should  be  employed;  transfusion  is  sometimes  necessary. 

Strapping. — When  the  hemorrhage  persists,  this  method  may  be  advan- 
tageously employed  :  A  pad  is  placed  in  the  axilla  and  over  the  femoral 
veins,  and  secured  with  a  strap  drawn  just  tight  enough  to  arrest  the 
flow  of  venous  blood  without  affecting  the  arterial  circulation.  Only 
two  or  three  extremities  should  be  thus  treated  at  one  time,  and  one 
compress  should  be  removed  to  the  free  extremity  every  15  minutes. 
In  this  manner  a  considerable  quantity  of  blood  can  be  withdrawn  from 
the  general  circulation. 


2  20  PRACTICE  OF  MEDICINE 

Fjieiimatic  Treatme?it — The  pneumatic  cabinet  is  now  seldom  employed, 
since  its  effect  is  believed  to  be  only  psychical.  The  patient  v/as  placed 
in  a  hermetically  closed  chamber  and  inhaled  rarefied  air.  Complete 
expansion  and  collapse  of  the  air-cells  was  believed  to  be  secured  at 
each  respiration. 

Specific  Treafmeni. — The  treatment  with  tuberculin  has  been  almost 
entirely  abandoned  everywhere,  on  account  of  unfortunate  results  which 
were  repeatedly  observed  after  its  administration.  The  new  tuberculin 
(TR)  has  been  found  even  more  dangerous  than  the  original.  When 
used,  it  is  injected  in  doses  of  i-iooo  to  1-500  milligram  once  or  twice 
a  week,  gradually  increasing  the  dose  until  slight  reaction  is  obtained. 

A  serum  obtained  from  animals,  especially  the  horse,  which  have 
been  rendered  immune  by  repeated  inoculations,  has  been  tried  during 
the  last  few  years,  but  while  it  apparently  exerts  a  beneficial  eftect  on 
the  fever  and  sweats,  the  results  have  not  confirmed  the  hope  that  a 
cure  had  been  found. 

LEPROSY. 

LEPRA. 

Leprosy  is  one  of  the  oldest  known  contagious  diseases.  Although  it  is  now  much 
less  prevalent  than  it  was  several  centuries  ago.  it  is  still  common  in  India  and  China. 
It  is  rarely  seen  in  the  United  States,  but  it  is  not  infrequent  in  the  West  Indies;  and 
in  the  Hawaiian  Islands  it  is  so  common  that  the  Island  of  Molokai  has  been  reserved 
for  the  segregation  of  its  victims.  Foci  of  the  disease  have  existed  for  a  number  of 
years  also  in  New  Brunswick  and  Nova  Scotia,  and  leprous  immigrants  have  recently 
reached  ^ilinnesota.  The  disease  is  occasionally  seen  in  the  South,  especially  at  New 
Orleans,  and  among  the  Chinese  along  the  Pacific  Coast. 

Definition. — A  chronic  infectious  disease  caused  by  the  bacillus  leprce 
and  characterized  by  the  formation  of  granulomatous  nodules  in  the 
skin  and  mucous  membranes ;  changes  in  the  nerves,  which  lead  to  an- 
esthesia and  trophic  disturbances  in  the  skin  and  other  tissues;  and 
constitutional  disturbances. 

Etiology. — The  bacillus  leprs  of  Hansen  closely  resembles  that  of 
tuberculosis  in  form  and  staining,  but  a  relation  between  the  two  organ- 
isms has  been  neither  proved  nor  disproved.  The  leprosy  bacillus  has 
not  been  reproduced  by  inoculation,  but  Von  Babe's  and  Kalindero 
report  that  lepers  react  in  the  same  manner  as  tuberculous  persons 
to  tuberculin.  An  individual  susceptibility  is  believed  to  be  necessar\" 
to  the  development  of  the  disease.  Men  are  more  frequently  affected 
than  wom.en  and  oftenest  in  the  third  decade  of  life.  There  is  no  ra- 
cial immunity,  but  the  dark  races  are  more  generally  affected  than 
the  light. 

Three  modes  of  communicating  the  disease  are  recognized;  namely, 
by  inoculation,  by  contagion,  and  by  heredity.  The  slow  development 
of  the  lesions  is  the  chief  obstacle  to  the  recognition  of  the  source  of 
infection. 

(i)  Inoculation. — A  criminal  in  Hawaii  was  inoculated  with  leprous 
tissue  in  1884,  and  died  of  the  disease  six  years  afterward,  but  there 
remained  a  possibility  of  his  having  contracted  it  from  some  other 
source.     A  leprous  nodule  at  the  point   of  inoculation   was,   however, 


LEPROSY 


221 


regarded  as  evidence  of  the  success  of  the  experiment.  The  disease  is 
beheved  to  have  been  conveyed  by  vaccination.  It  is  an  interesting 
fact  that  leprosy  and  mosquitoes  arrived  in  Hawaii  simultaneous!}-, 
presumably  from  China. 

(2)  Contagion.— Th.Q  bacilli  are  found  in  great  numbers  in  the  saliva 
and  mucus  from  the  mouth  and  nostrils  of  individuals  having  lep- 
rous lesions  in  those  parts  and  in  the  open  sores  wherever  situated. 
Hence  the  custom  of  kissing,  or  that  of  "rubbing  noses,"  as  practiced 
in  Hawaii,  has  been  looked  upon  as  a  common  mode  of  conveying  the 
virus.  This  mode  is  especially  insisted  upon  by  Sticker,  who  found  the 
primary  lesion  commonly  in  the  nose.  Bacilli  are  found  also  in  the 
urine  and  milk  of  lepers.  The  contagiousness  of  the  disease  has  been 
recognized  from  the  time  of  Moses  and  has  been  established  by  numer- 
ous examples. 

It  is  probable  that  close  contact  is  necessary  to  contagion,  since 
physicians  and  nurses  usually  escape  infection,  although  coming  into 
ordinary  contact  with  the  disease  for  many  years. 

(3)  Heredity. — The  old  belief  that  the  disease  is  transmitted  by  hered- 
ity has  been  abandoned,  since  the  lesions  are  not  found  at  birth,  and  the 
opportunities  of  contagion  during  infancy  and  childhood  are  many. 

The  disease  has  long  been  attributed  to  the  eating  of  fish,  but  there 
is  little  evidence  that  the  bacilli  can  be  derived  from  this  source.  It  is 
doubtless  often  conveyed  by  cups,  pipes,  and  other  articles  which  have 
been  used  by  the  leper. 

Morbid  Anatomy. — The  typical  lesion  is  a  granulomatous  nodule  of 
variable  size,  usually  termed  a  tubercle,  in  the  skin  or  a  mucous  mem- 
brane. This  consists  of  epithelioid,  lymphoid,  and  giant  cells  in  a  con- 
nective-tissue stroma,  within  and  between  which  are  numerous  bacilli. 
In  the  anesthetic  type  of  the  disease  the  bacilli  enter  the  peripheral 
nerve  fibers  and  produce  neuritis.  They  have  been  seen  also  within  the 
cells  of  the  spinal  cord.  The  face  and  hands  and  in  some  cases  the 
integument  of  a  greater  part  of  the  body  become  disfigured  by  large 
nodules.  Later  these  nodules  show  a  tendency  to  soften ;  they  frequently 
separate  and  form  large  ulcers  which  persist  indefinitely  and  gradually 
invade  surrounding  tissues.  The  fingers  and  toes  often  slough  away. 
The  mucous  membranes,  particularly  that  of  the  larynx,  the  cornea, 
and  conjunctiva,  are  frequently  invaded  and  to  a  great  extent  destroyed. 
The  internal  organs,  especially  the  lungs,  liver,  spleen,  are  often  the 
seat  of  nodular  formations. 

Symptoms. — The  first  symptom  observed  in  many  cases  is  a  catarrh, 
a  "cold,"  or  rhinitis,  with  sneezing  and  itching  of  the  nose.  This  is 
thought  to  render  active  bacilli  which  may  have  been  latent.  Other 
prodromal  symptoms,  as  digestive  disorders,  anorexia,  sometimes  epis- 
taxis  and  prostration,  are  often  observed.  After  this  the  disease  develops 
in  either  of  two  forms,  the  tubercular  or  the  anesthetic,  but  as  a  rule 
both  forms  are  later  found  in  the  same  patient. 

I.  Tubercular  Leprosy.— The  disease  appears  in  the  skin  as  an  ery- 
thematous, distinctly  defined,  or  macular  rash,  often  with  hyperesthesia. 
Burning  pain  and  itching  are  commonly  present.  The  color  of  the  af- 
fected area  becomes  dark  from  a  deposit  of  pigment,  but  later  it  often 
loses  its  color  and   becomes   "white  as  snow"  and  totally  anesthetic 


222  PRACTICE  OF  MEDICINE 

(lepra  alba).  This  stage  may  be  repeated  more  or  less  constantly  dur- 
ing- the  course  of  the  entire  disease.  A  remittent  type  of  fever  is  almost 
invariably  present  in  the  beginning  of  this  form  of  the  disease.  Nodules 
then  make  their  appearance  in  the  affected  areas  when  they  are  situated 
on  any  part  of  the  body  except  the  scalp.  They  are  especially  large 
in  growth  upon  the  face,  arms,  and  legs,  often  reaching  the  diameter  of 
3,(1  inch  (2  cm.),  and  sometimes  coalescing  to  form  yet  larger  promi- 
nences. The  hair  of  the  face  falls  out.  The  eye  and  the  mucous  mem- 
branes of  the  mouth,  pharynx,  and  larynx  are  often  invaded.  The  face 
acquires  a  lion-like  appearance,  which  has  given  the  name  leontiasis  to 
the  condition.  More  or  less  destructive  ulceration  often  occurs  in  and 
between  the  nodules,  ultimately  destroying  the  bridge  of  the  nose,  the 
eyeballs,  fingers,  and  toes.  The  appearance  of  the  patient  becomes  most 
loathsome,  but  owing  to  the  anesthesia  the  suffering  is  not  usually  great. 
The  progress  of  the  disease  is  extremely  slow. 

2.  Anesthetic  Leprosy. — This  form  of  the  disease,  although  undoubt- 
edly of  the  same  nature  as  the  tubercular,  frequently  bears  no  resem- 
blance to  it.  In  it  areas  of  hyperesthesia,  pain,  or  numbness  replace 
those  of  erythema.  If  the  peripheral  nerve  trunks  could  be  examined  at 
this  time,  they  would  be  found  enlarged  by  the  formation  of  small  nod- 
ules which  can  sometimes  be  felt  through  the  skin.  Soon  after  the 
development  of  pain  there  may  be  a  formation  of  small  bullae  as  a 
result  of  trophic  changes  in  the  skin.  The  hair  of  the  affected  area 
falls  and  the  perspiration  is  arrested,  so  that  the  skin  is  always  dry. 
Following  the  bullae,  ulcers  are  formed  which  soon  become  necrotic 
and  fetid.  Peculiar  contractures  of  the  hands  and  feet  often  occur  owing 
to  the  affection  of  the  muscles,  and  a  perforating  ulcer  is  not  infre- 
quently formed,  especially  on  the  foot.  The  fingers  and  toes,  as  in  the 
tubercular  form,  become  necrotic  and  drop  off.  An  entire  hand  or  foot 
is  sometimes  amputated.  But  the  disease  may  last  many  years  before 
these  destructive  manifestations  appear,  and,  indeed,  many  years  after- 
ward. 

Diagnosis. — The  peculiar,  erythematous,  hyperemic,  or  anesthetic  pig- 
mented patches  are  characteristic  of  no  other  disease.  After  the  nod- 
ules, ulcers,  anesthesia,  or  contractures  have  become  well  developed, 
there  is  no  possibility  of  error.  The  microscopic  examination  of  an 
excised  nodule  establishes  the  diagnosis.  The  bacilli  may  be  found  in 
the  nose  or  mouth.  Since  animals  cannot  be  inoculated  with  them, 
this  is  one  of  the  best  methods  of  excluding  tuberculosis. 

Prognosis. — The  disease  is  incurable.  It  almost  invariably  progresses 
to  a  fatal  termination.  The  tubercular  form  usually  lasts  about  10 
years,  the  anesthetic  20.  Death  sometimes  occurs  comparatively  early 
from  the  involvement  of  the  larynx  and  the  development  of  aspiration 
pneumonia.  Spontaneous  cure  is  sometimes  observed,  especially  in  the 
early  stages.  The  duration  of  the  disease  depends  much  upon  the 
strength  of  the  individual. 

Treatment. — Isolation  and  segregation  are  the  only  prophylactic  meas- 
ures. Fortunately  there  are  many  institutions  for  this  purpose  in  lep- 
rous countries.  The  treatment  of  the  patient  is  confined  to  the  admin- 
istration of  remedies  to  retard  progress.  General  tonics,  abundant 
nutritious  food,  and  frequent  bathing  are  the  chief  elements  of  treatment. 


TETANUS  223 

Arsenic,  potassium  iodid  in  large  doses,  gurjun  oil  in  v\x  (0.60)  doses, 
and  chaulmoogra  oil  in  doses  gradually  increasing  to  3  iij  (ii.o)  are 
most  employed. 

TETANUS. 

LOCKJAW. 

Definition. — An  acute  infectious  disease  caused  by  the  tetanus  bacillus 
and  producing  as  its  chief  symptom  a  tonic  spasm  of  the  muscles,  es- 
pecially those  of  the  jaw  and  neck. 

Etiology. — The  tetanus  bacillus,  the  recognized  cause  of  the  disease, 
is  a  short,  motile,  club-shaped,  spore-bearing  bacillus,  one  extremity  of 
which  is  expanded  into  a  little  head  or  bead.  It  is  capable  of  indepen- 
dent existence  in  damp  earth,  as  that  of  cellars  and  gardens,  and  in 
manure.  Hence  the  disease  is  especially  liable  to  follow  injuries  of 
the  hand  or  foot  by  objects  embedded  in  foul  earth.  It  is  a  particularly 
common  result  of  injuries  by  the  toy  pistol,  the  virus  probably  being 
present  on  the  hands  before  injury.  The  disease  often  seems  to  be 
endemic  in  certain  places.  It  has  assumed  epidemic  proportions  in  some 
instances,  particularly  during  wars.  An  idiopathic  form  of  it  is  gener- 
ally recognized,  in  which  it  develops  in  the  absence  of  recognizable 
trauma.  The  tetanus  of  the  newborn  babe  (trismus  neonatorum)  is 
generally  regarded  as  of  this  character,  but  it  is  possible  that  infection 
sometimes  takes  place  through  the  umbilicus. 

Morbid  Jin  atomy.— The  lesions  found  after  death  are  not  distinctive. 
The  bacillus  has  been  found  in  the  discharge  from  wounds,  in  the  spinal 
cord,  and  in  the  peripheral  nerves  near  the  site  of  inoculation.  The 
brain  and  cord  are  hyperemic;  the  nerve-cells  are  in  a  state  of  granu- 
lar degeneration,   and  perivascular  exudations  are  usually  found. 

Symptoms. — The  incubation  generally  lasts  from  10  days  to  two  weeks. 
The  onset  may  be  marked  by  chilly  sensations,  rarely  by  a  distinct 
rigor;  but  very  often  stiffness  of  the  jaw  and  sides  of  the  neck  is  first 
noticed  on  account  of  the  interference  with  swallowing.  The  stiffness 
soon  develops  into  a  tonic  spasm  affecting  the  jaw  and  back  of  the 
neck,  tightly  closing  the  mouth  and  producing  lockjaw.  In  most  cases 
there  is  a  contraction  of  the  muscles  of  the  face,  raising  the  eyebrows, 
wrinkling  the  forehead,  and  drawing  down  the  angles  of  the  mouth,  thus 
producing  the  so-called  sardonic  grin.  The  pupils  are  generally  contract- 
ed. In  children  the  spasm  may  be  confined  to  the  muscles  of  the  face  and 
jaw.  In  adults  the  muscles  of  the  back  of  the  neck  or  those  of  the 
entire  spinal  region  become  rigid,  drawing  the  head  back  so  that  the 
body  rests  upon  the  head  and  buttocks  (opisthotonos),  or  in  extreme 
cases  on  the  head  and  heels  (orthotonos).  In  some  instances  the  muscles 
of  only  one  side  are  affected  (pleurothotonos).  A  rigidity  of  the  abdomi- 
nal muscles,  with  flexion  forward  (emprosthotonos),  has  been  observed. 

In  many  cases  the  tonic  spasms  are  interrupted  by  paroxysms  in 
which  the  contracted  muscles  become  still  more  rigid,  or  in  which  a 
clonic  spasm  occurs.  The  muscles  jerk  violently  and  often  raise  the 
patient  from  his  bed.  Rupture  of  a  muscle  is  not  unusual  during  the 
seizures.  The  suffering  at  these  times  is  intense,  although  the  tetanic 
contractions  may  not  be  painful.    The  skin  is  generally  bathed  in  a  cold 


2  24  PRACTICE  OF  MEDICINE 

sweat.  The  spasms  may  be  induced,  as  in  hydrophobia,  by  the  most 
trivial  irritation,  a  draft  of  air,  noise,  or  jarring  of  the  bed.  Fever 
may  be  present  or  absent.  The  temperature  may  reach  105°  or  106°  F. 
(40.5° — 41°  C),  and  often  runs  up  to  110°  F.  (43.3°  C.)  shortly  before 
death.  A  peculiar  form  of  the  disease  is  that  known  as  head-tetanus, 
which  usually  results  from  wounds  on  one  side  of  the  head.  The  symp- 
toms are  paralysis  of  the  face  muscles  on  the  side  of  the  injury,  and 
dififiiculty  in  sv/allowing  on  account  of  rigidity  of  the  jaw. 

Diagnosis. — These  conditions,  following  a  trauma,  could  not  well  be  mis- 
taken for  any  other  disease.  In  strychnin-poisoning,  spasms  occur,  but  they 
affect  the  entire  body,  including  the  arms,  which  are  seldom  affected  in  tet- 
anus.   In  the  intervals  between  the  spasms,  the  muscles  become  relaxed. 

In  hysteria  the  convulsions  are  usually  general  in  character  and  the 
temperature  is  normal.     Complete  relaxation  occurs  in  the  intervals. 

In  tetany  the  spasm  involves  the  face,  hands,  and  feet.  If  there  is 
rigidity  of  the  jaw,  it  is  one  of  the  late  manifestations. 

In  hydrophobia  there  is  difficulty  in  swallowing,  but  the  jaw  is  not 
rigid  and  there  is  no  opisthotonos. 

Prognosis. — The  mortality  in  traumatic  cases  is  from  80  to  90  per 
cent.  In  acute  cases  death  usually  occurs  in  from  one  to  seven  days. 
When  the  onset  is  gradual  and  the  case  lingers  for  a  week,  the  prognosis 
becomes  more  favorable.    Infants  invariably  die. 

Treatment. — When  the  patient  is  seen  immediately  after  receipt  of 
the  injury,  thorough  cauterization  may  be  practiced  with  hope  of  de- 
stroying the  virus.  Complete  excision  of  the  wound  is  a  more  certain 
measure.  But  after  the  disease  has  developed,  little  can  be  anticipated 
from  either  practice.  Good  results  have  followed  the  early  injection  of 
an  antitoxic  ("antitetanic")  serum  in  a  few  cases.  Bacelli  and  others 
have  also  employed  successfully  a  2  or  3  per  cent  solution  of  carbolic 
acid,  the  quantity  of  the  acid  used  aggregating  gr,  ]^  to  ys  (0.03  to 
0.04)  in  each  24  hours.  The  spasms  should  be  controlled,  as  far  as 
possible,  by  the  administration  of  chloroform  by  inhalation,  and  by  the 
internal  administration  of  the  bromids  and  chloral,  or  b_y  morphin 
hypodermically  if  necessary.  The  patient  should  lie  in  a  quiet,  dark- 
ened room,  carefully  protected  from  injury  during  the  seizures.  Nour- 
ishment must  be  given  by  the  rectum  or  by  means  of  a  catheter  passed 
through  the    nostril. 

INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE. 

FEBRICULA. 

SIMPLE  CONTINUED  FEVER,  EPHEMERAL  FEVER. 

Definition. — A  mild  fever  of  short  duration,  due  to  a  variety  of 
causes  and  unattended  with  definite  lesions.  The  term  ephemeral  fever 
is  generally  restricted  to  the  class  of  cases  which  last  only  a  day; 
while  febricula  or  simple  continued  fever  is  applied  to  those  which 
last  from  2  or  3  to  14  days. 

Etiology. — With  reference  to  cause,  there  are  three  groups  of  cases — 
the  gastrointestinal,  the  nervous,  and  the  infectious. 


ACUTE  FEBRILE  JAUNDICE  225 

(i)  Gastrointestinal  Group. — Most  cases  are  due  to  a  disturbance  of 
digestion.  This  is  especially  frequent  in  children.  It  is  doubtless  often 
of  the  nature  of  ptomain-poisoning,  due  to  the  absorption  of  poison- 
ous substances  from  the  intestinal  canal,  following  the  ingestion  of  de- 
composed food. 

(2)  Nervous  6^/-^///.— Nervous  excitement  or  exhaustion  is  a  common 
cause.  This  frequently  results  from  exposure  to  excessive  heat  (inso- 
lation), worry,  the  excitement  of  receiving  visitors  while  ill  from  another 
disease,  or  removal  to  a  hospital.  In  nervous  persons  it  may  result 
from  witnessing  a  serious  accident  to  another,  rarely  from  meditating 
upon  some  public  calamity.  It  is  possible  that  many  cases  in  which 
fever  follows  exposure  to  foul  odors  or  sewer  gas  are  of  this  type,  since 
those  constanth'  exposed  to  them  are  rarely  affected;  other  cases  are 
perhaps  due  to  ptomain-poisoning  conveyed  by  the  gas,  and  belong  to 
the  next  group. 

(3)  Infectious  Group. — This  includes  abortive  cases  of  the  infectious 
diseases,  cases  that  begin  with  the  initial  symptoms  of  typhoid  fever, 
measles,  scarlet  fever,  or  other  infection,  but  gradually  subside  after  a 
few  days,  and  cases  in  which  the  exanthem  fails  to  appear.  In  it  may 
be  included  also  the  mild  fever  that  occurs  in  some  cases  of  rheumatism, 
pharyngitis,  tonsilitis,  bronchitis,  and  lymphadenitis. 

Sympioms. — Fever  is  the  essential  symptom.  In  some  cases  it  sets  in 
abruptly,  in  others  it  is  preceded  by  slight  malaise.  There  may  be  slight 
chilliness,  flushing  of  the  cheeks,  headache,  pain  in  the  back  and  Hmbs, 
loss  of  appetite,  furred  tongue,  constipation,  restlessness  and  insomnia. 
The  fever  ranges  from  101°  to  103°  F.  (38.0°  to  39.0°  C).  The  usual 
accompaniments  of  temperature  elevation  are  present,  as  thirst,  depres- 
sion, and  concentration  of  urine.  High  fever,  with  delirium,  is  sometimes 
observed  in  children. 

Diagnosis. — The  diagnosis  is  to  be  arrived  at  by  exclusion.  Febricula 
should  be  the  last  item  in  the  list  considered.  It  is  rather  a  name  to 
be  given  to  a  febrile  condition  which  is  unaccompanied  by  pathological 
lesions  to  justify  another  diagnosis.  Too  often,  perhaps,  it  implies  an 
inability  to  arrive  at  a  correct  solution  of  the  case.  Typhoid  fever  is 
distinguished  by  the  severity  and  duration  of  the  prodromal  symptoms 
and  gradual  rise  of  temperature;  malaria,  by  its  periodicity  and  the 
presence  of  the  plasmodium;  sepsis,  by  the  presence  of  suppuration, 
repeated  chills,  and  sweating.  In  the  exclusion  of  other  conditions,  it 
is  necessary  to  examine  the  ear,  throat,  chest,  and  all  parts  of  the 
bod}-.     The  skin  should  be  examined  daily  for  an  exanthem. 

Prognosis.— True  febricula  always  terminates  in  recovery. 

Treatment.— Rest  in  bed,  the  administration  of  a  laxative,  cooling, 
acidulated  drinks,  and  liquid  diet  are  generally  all  that  is  required.  If 
the  fever  is  above  101°  F.  (38.0°  C.)  it  may  be  reduced  by  cool  sponging, 
a  bath  of  75°  F.  (25.0°  C.),  or  a  few  doses  of  phenacetin. 

ACUTE   FEBRILE  JAUNDICE. 

WEII.-S  DISEASE. 

Definition.— An  acute  febrile  disease,  probably  a  specific  infection,  ac- 
companied by  fever,  jaundice,  nephritis,  and  pains  in  the  muscles. 

15 


226  PR.\CTICE  OF  MEDICINE 

Etiology. — A  bacillus  proteus  fluorescens  has  been  described  as  the 
specific  cause  by  Jaeger,  but  there  is  still  much  doubt  as  to  the  identity 
of  the  disease.  Some  writers  regard  it  as  simply  a  febrile  icterus  due 
to  one  of  several  causes.  It  usually  occurs  in  summer,  oftenest  in  men 
between  30  and  50  years  of  age.  It  sometimes  attacks  a  number  of 
persons  in  the  same  locality,  as  a  group  of  soldiers,  or  those  of  the 
same  occupation,  notabty  butchers. 

Morbid  Anatomy. — There  is  usually  hyperemia  of  the  intestines,  liver, 
and  spleen  and  a  mild  acute  desquamative  nephritis,  lesions  which  cannot 
be  regarded  as  typical. 

Symptoms. — The  onset  is  generally  abrupt,  with  chill,  headache,  and 
pain  in  the  back  and  legs  and  often  in  the  muscles,  especially  of  the 
cheek.  The  fever  is  remittent.  Jaundice  appears  on  the  second  day 
and  may  deepen  on  succeeding  days.  Gastrointestinal  disorders  are 
occasionally  present.  The  stools  are  sometimes  clay-colored.  The  fever 
lasts  about  a  week  and  subsides  by  lysis;  it  does  not  usually  exceed 
103.5°  -P-  C39'5°  C.).  Nervous  symptoms  sometimes  develop,  as  rest- 
lessness, occasionally  delirium  or  coma.  The  liver  and  spleen  become 
enlarged,  and  albuminuria  is  present  with  casts,  epithelium,  rarely  blood- 
cells. 

Miiller  has  described  a  form  in  which  jaundice  is  absent.  An  epidemic 
of  it  occurred  in  1891  near  Breslau.  It  has  been  described  also  under 
the  name  Schlammfieber.    Recovery  usually  occurs. 

Treatment. — The  treatment  is  that  of  catarrhal  jaundice. 


GLANDULAR  FEVER. 

Definition. — An  acute  infection  of  childhood  distinguished  by  fever, 
and  swelling  of  the  cervical  lymph-glands. 

Etiology. — The  specific  cause  is  unknown.  The  disease  has  been  rec- 
ognized in  epidemic  form  in  a  few  instances,  notably  by  Pfeiffer,  in 
Germany,  in  1889,  and  by  West,  in  Ohio,  in  1893.  It  attacks  children 
between  the  seventh  month  and  the  thirteenth  year.  Outbreaks  are 
sometimes  limited  to  all  the  children  of  a  single  family. 

Symptoms. — The  onset  is  sudden,  the  first  symptom  usually  being 
pain  and  tenderness  over  the  region  of  the  cervical  lymph-glands,  ag- 
gravated by  mo\dng  the  head.  There  are  sometimes  abdominal  distress, 
nausea,  constipation,  and  fever  reaching  102°  or  103°  F.  (39.0° — 39.5° 
C).  On  the  second  or  third  day  the  glands,  especially  those  of  the 
carotid  region,  and  in  the  majority  of  instances  also  the  postcervical, 
axillary,  and  inguinal,  become  much  swollen  and  tender.  The  internal 
glands — the  bronchial,  tracheal,  and  mesenteric — may  be  affected.  The 
tonsils  are  red  and  swollen  in  some  cases.  The  liver  and  spleen  are 
enlarged.  Otitis,  bronchitis,  and  acute  nephritis  have  been  observed  as 
complications.  The  fever  usually  lasts  only  a  few  days;  the  swelling  of 
the  glands  continues  about  two  weeks,  then  slowly  subsides.  Suppura- 
tion is  extremely  rare. 

The  prognosis  is  good. 

Treatment  is  symptomatic.  Hot  or  cold  applications  may  be  em- 
ployed to  relieve  pain.     Park  warns  against  purgative  doses  of  calomel. 


MOUNTAIN  FEVER  227 

Diarrhea  should  not  be  too  hastily  checked.    Tonics  including  iron  are 
required  in  convalescence. 


MOUNTAIN  FEVER. 

Definition. — A  peculiar  febrile  condition  induced  by  ascent  to  high 
altitudes.  The  condition  is  not  specific,  and  there  is  very  little  reason 
to  regard  it  as  a  distinct  disease. 

Etiology. — The  only  cause  is  the  influence  of  the  rarefied  atmosphere. 
Several  other  diseases  have  been  repeatedly  reported  as  mountain  fever. 
These  have  been  for  the  most  part  atypical  cases  of  typhoid  fever.  A 
mountain  anemia  due  to  the  anchylostoma  has  also  been  described 
under  this  name. 

Symptoms.— The  ascent  to  moderate  heights,  less  than  15,000  feet, 
causes  in  some  persons  a  feeling  of  giddiness  with  moderate  dyspnea, 
which  precludes  exertion.  Ascent  to  greater  heights,  as  described  by 
Whymper  in  his  ascent  of  Mt.  Chimborazo,  causes  at  a  height  of  16,664 
feet  headache,  gasping  for  breath,  dryness  of  the  throat,  intense  thirst, 
loss  of  appetite,  and  general  malaise,  with  slight  elevation  of  tempera- 
ture, in  this  instance  100.4°  F-  (38°  C).  The  condition  lasted  for  three 
days.  Epistaxis  and  hemoptysis  occasionally  occur  at  even  lower  levels. 
Zangger  has  recently  shown  that  rapid  ascent  to  high  altitudes  is  at- 
tended also  with  great  danger  of  cardiac  thrombosis  and  pulmonary 
embolism,  especially  in  elderly  persons.  These  seizures  often  do  not  de- 
velop until  two  or  three  days  after  descent. 

Treatment. — The  febrile  condition  calls  only  for  rest.  Return  to  a 
lower  altitude  gives  immediate  relief.  The  system  becomes  accustomed 
to  the  atmospheric  condition  in  a  few  days. 

"SPOTTED  FEVER  OF  THE  ROCKY  MOUNTAINS. 

BLACK  FEVER,  BLUE  DISEASE. 

Under  this  provisional  name  an  interesting  disease  has  been  described 
as  observed  in  the  Bitter  Root  and  Solo  valleys  of  Montana  and  Idaho, 
by  E.  E.  Maxey,  in  the  Medical  Sentinel,  October,  1899,  and  by  L.  B.  Wil- 
son and  W.  M.  Chowney,  in  the  Journal  of  the  American  Medical  Associa- 
tion, 1902,  Vol.  xxxix.  p.  131. 

Definition.— Axi  acute  infectious  disease  of  the  Rocky  Mountain  region, 
characterized  by  chills,  fever,  prostration,  slight  jaundice,  and  an  eruption 
of  macules  which  often  coalesce  to  form  a  marmorated  surface. 

Etiology.— The  specific  cause  is  believed  to  be  a  protozoon  found  in 
the  red  blood-corpuscles.  The  medium  of  infection  is  thought  to  be 
a  species  of  tick,  and  the  gopher  perpetuates  the  disease.  It  is  not 
contagious.  It  occurs  only  in  a  limited  area  of  40x20  miles  and  only 
from  March  to  July.  It  attacks  persons  of  any  age  and  of  either  sex; 
the  Indians  are  apparently  immune. 

Morbid  Anatomy.— The  ma,rmorated  appearance  of  the  skin  persists, 
and  the  bites  of  the  tick  can  usually  be  found.  The  liver  and  spleen 
are  moderately  enlarged;  the  other  organs  normal.    Petechiae  are  some- 


2  2S  PRACTICE  OF  MEDICINE 

times  found  in  the  pericardium.  The  hematazoon  is  found  in  the  blood, 
liver,  and  spleen. 

Symptoms. — In  some  cases  there  is  a  short  period  of  malaise.  The 
invasion  is  with  marked  chill,  which  recurs  at  irregular  intervals  with 
decreasing  severity.  In  the  beginning  there  is  severe  pain  in  the  head, 
back,  bones,  joints,  and  muscles,  and  great  prostration.  Constipation 
is  usual.  The  skin  is  dry,  often  puffy,  but  it  does  not  pit.  The  tongue 
is  heavily  coated,  becoming  brown  and  fissured.  Sordes  are  pronounced. 
The  appearance  is  like  that  of  typhoid  fever.  The  temperature  rises 
after  the  chill  to  103°  or  104°  F,  (39-5°— 40°  C.)  and  gradually  in- 
creases for  five  to  seven  days  to  105°  or  107°  F.  (40.5° — 41.5°  C), 
and  declines  by  a  lysis  of  about  two  weeks.  It  sometimes  becomes 
normal  or  subnormal  shortly  before  death.  Low  muttering  delirium 
may  occur  at  this  stage.  The  pulse,  at  first  slow  and  strong,  increases 
up  to  150  and  becomes  feeble.  Both  pulse  and  respiration  are  rapid 
beyond  the  ratio  to  the  temperature.  Nausea  and  vomiting  generally 
develop  in  the  second  week  and  continue  to  the  end  in  fatal  cases.  There 
is  moderate  anemia  and  leucocytosis. 

The  macular,  rose-colored  eruption  appears  by  the  second  to  the  fifth 
day  on  the  wrists,  ankles,  and  back  and  rapidly  spreads  to  the  entire  body. 
The  spots  are  at  first  discrete,  i  to  5  mm.  in  diameter,  but  soon  become 
dark  and  coalesce,  giving  the  skin  a  mottled  appearance,  especially  on 
dependent  parts.  It  sometimes  remains  discrete;  occasionally  it  is  absent 
in  mild  cases.  Slight  jaundice  is  present,  noticeable  especially  in  the 
conjunctivae.  The  skin  becomes  glazed  in  the  second  week,  and  a  slight 
desquamation  begins  in  the  third.  The  eruption  vanishes  with  the 
fever.  Gangrene  sometimes  sets  in  shortly  before  death,  in  the  elbows, 
fingers,  toes,  lobes  of  the  ear,  and  elsewhere.  Hypostatic  pneumonia 
may  develop.     The  disease  lasts  about  four  weeks. 

Prognosis. — Mild  cases  are  encountered,  but  in  well-marked  cases  the 
mortality  is  about  80  per  cent. 

Treatment. — No  specific  treatment  has  been  proposed,  further  than 
that  of  other  febrile  diseases,  particularly  typhoid  fever. 

MILIARY  FEVER. 

SWEATING  SICKNESS. 

Definition. — An  acute  epidemic  infection  characterized  by  profuse  sweat- 
ing and  an  eruption  of  miliary  vesicles. 

Etio/ogy.~The  disease  has  not  been  recognized  in  this  country,  but 
it  occasionally  assumes  the  form  of  a  limited  epidemic  in  France,  Italy, 
and  Austria.  A  fatal  type  of  it  prevailed  in  England  in  the  fifteenth 
and  sixteenth  centuries.  It  is  more  frequentl}'  encountered  in  females. 
The  specific  cause  is  not  known.  The  epidemic  usually  spreads  with 
great  rapidity. 

Symptoms. — The  onset  is  sudden,  with  fever,  frequent  sweating,  epi- 
gastric oppression,  and  marked  prostration.  An  erythematous  rash 
appears,  and  by  the  third  or  fourth  day  this  gives  place  to  an  eruption 
of  miliary  vesicles,  chiefly  on  the  neck  and  axillae,  sometimes  on  the 
mucous    membranes.     In    mild   cases  the  fever  is  slight,  but  in  severe 


GLANDERS  229 

cases  there  are  evidences  of  intense  toxemia,  high  fever,  profound  pros" 
tration,  deHrium,  and  sometimes  hemorrhages.  Death  may  occur  within 
a  few  hours.  Pregnant  women  abort  and  usually  die.  The  average 
mortality  is  only  8  or  9  per  cent,  but  in  epidemics  it  has  been  higher. 

Treaimeni. — The  treatment  is  chiefly  symptomatic.  Quinin  is  gener- 
ally prescribed. 

INFECTIOUS  DISEASES  COMMON  TO   MAN  AND 
LOWER  ANIMALS. 

GLANDERS. 

FARCY. 

Definition. — An  infectious  disease  caused  by  the  bacillus  mallei  usually 
affecting  the  horse  or  other  animal  of  the  same  species,  and  occasionally 
acquired  by  man  through  inoculation.  It  occurs  in  two  forms  :  True 
glanders,  which  affects  the  nasal  cavity,  and  farcy,  in  which  nodules 
appear  beneath  the  skin.    Either  form  may  be  acute  or  chronic. 

Etiology. — The  bacillus  mallei  is  a  short,  non-motile,  rod  which  closely 
resembles  the  bacillus  tuberculosis.  It  is  found  in  the  nodules,  ulcers, 
and  abscesses,  and  in  the  discharges  from  them,  and  possibly  in  the  blood 
and  urine.  Infection  usually  occurs  through  the  inoculation  of  an 
abraded  surface  by  the  nasal  mucus  of  an  affected  horse,  ass,  or  mule. 
It  may  be  caused  by  the  inhalation  of  the  dried  mucus  or  by  trans- 
mission from  man  to  man. 

Morbid  Anatomy. — A  granulomatous  nodule  of  variable  size  is  the 
characteristic  lesion.  In  man  these  are  usually  small  and  consist  of 
lymphoid  and  epithelioid  cells,  within  and  between  which  the  bacilli  may 
be  seen  in  microscopic  section.  They  rapidly  disintegrate  and  leave  ulcers 
and  abscesses  in  the  skin,  subcutaneous  tissue,  muscles,  and  viscera. 

Symptoms. — An  acute  and  a  chronic  form  are  recognized  in  both  the 
true  glanders  and  in  farcy.  The  symptoms  usually  appear  within  three 
or  four  days  after  inoculation,  less  frequently  after  a  week  or  two. 

1.  Acute  Glanders. — The  first  manifestations  of  the  disease  are  gener- 
ally of  a  constitutional  character — fever,  with  headache,  and  pain  in  the 
extremities,  sometimes  suggestive  of  typhoid  fever.  The  point  of  in- 
oculation becomes  swollen,  painful,  and  surrounded  by  an  area  of  hyper- 
emia and  lymphangitis.  Within  two  or  three  days  small  nodules  appear 
in  the  nose,  which  break  down  and  discharge  a  saneous,  mucopurulent 
fluid.  The  nose  and  face  become  greatly  swollen.  Papules  and  vesicles 
appear  singly  or  in  groups  on  the  face,  sometimes  also  about  the  joints. 
These  soon  change  into  pustules,  hke  those  of  smallpox,  but  larger,  as 
a  rule.  Ulcers  then  form,  which  sometimes  lead  to  necrosis,  with  an 
exceedingly  offensive  discharge.  The  nearest  lymph-glands  become  much 
enlarged  and  the  disease  often  extends  to  the  pharynx,  mouth,  larynx, 
and  bronchi.  Broncho-pneumonia  may  follow.  The  constitutional  symp- 
toms are  severe  and  often  assume  a  pyemic  character,  with  chills,  fever, 
and  sweating,  vomiting,  diarrhea,  and  profound  prostration. 

2.  Acute  Juzrc}'.— The  first  manifestation  is  usually  a  local,  painful 
swelling  at  the  point  of  inoculation,  with  hyperemia  and  lymphangitis. 


23 o  PRACTICE  OF  MEDICINE 

Nodules  (farcy  buds)  form,  especially  along  the  course  of  the  lymphatics, 
and  rapidly  produce  abscesses.  Abscesses  may  form  also  about  the  joints 
and  in  the  muscles.  The  nose  is  not  affected,  and  the  superficial  ulcers 
of  the  skin  are  absent.    The  constitutional  symptoms  are  those  of  sepsis. 

3.  Chronic  Glanders- — This  form  is  rare  and  difficult  of  diagnosis. 
There  is  usually  a  fetid,  saneous,  or  mucopurulent  discharge  from  ulcers 
in  the  nose  which  resembles  that  of  syphilitic  ozena.  Subcutaneous 
nodules  may  also  form,  but  they  produce  little  local  or  constitutional 
reaction.    The  larynx  is  sometimes  affected. 

4,  Chronic  Farcy.— T\\^  nodules  generally  form  on  the  arms  or  legs, 
then  break  down  into  ulcers  and  abscesses  which  persist  for  months. 
Local  and  constitutional  disturbances  follow. 

Prognosis. — The  acute  forms  of  the  disease  usually  terminate  fatally 
within  8  to  15  days.  Recovery  from  farcy  has  been  reported.  Chronic 
glanders  terminates  fatally  in  from  2  to  3  weeks  as  a  result  of  broncho- 
pneumonia or  sepsis.  Chronic  farcy  may  last  for  several  months,  ulti- 
mately ending  in  death  from  exhaustion  or  sepsis.  Recovery  sometimes 
occurs. 

Treatment. — The  site  of  the  original  inoculation  should  be  promptly 
destroyed  with  the  hot  iron  or  pure  nitric  acid.  The  farcy  buds  should 
be  incised  and  cauterized  or  injected  with  a  i  :20  solution  of  carbolic 
acid.  In  glanders  the  nostrils  should  be  frequently  irrigated  with  a 
I  :iooo  solution  of  mercuric  chlorid.  The  strength  of  the  patient  must 
be  supported  by  the  free  administration  of  stimulants,  animal  food,  and 
full  doses  of  strychnin.  A  toxin,  mallein,  prepared  from  cultures  of  the 
bacillus,  has  been  employed  in  the  treatment  of  animals  and  for  diagnos- 
tic purposes. 

HYDROPHOBIA. 

RABIES. 

Definition.— kxi  acute  infection  of  man  and  animals,  generally  com- 
municated through  inoculation  and  manifested  by  spasms  of  the  muscles 
of  deglutition  and  respiration,  with  other  indications  of  disturbance  of 
the  central  nervous  system. 

Etiology. — The  disease  is  peculiar  to  warm-blooded  animals,  partic- 
ularly the  carnivora.  The  dog,  cat,  wolf,  fox,  and  skunk  are  especially 
liable  to  it,  but  many  other  animals  are  susceptible  to  inoculation, 
notably  the  horse,  ox,  and  pig.  The  disease  is  probably  more  prevalent 
in  Russia  and  Siberia  than  elsewhere.  It  is  communicated  to  man 
chiefly  through  the  bite  of  a  rabid  animal.  Bites  on  the  exposed  parts 
of  the  body  are  especially  dangerous;  since  the  clothing,  when  pene- 
trated by  the  teeth,  may  remove  much  of  the  virus.  The  saliva  of  a 
rabid  animal,  whether  violent  or  "  dumb,"  is  capable  of  inoculating  an 
abraded  surface. 

The  specific  micro-organism  has  not  been  discovered,  but  the  toxin- 
has  been  separated  from  the  nerve  substance,  saliva,  and  other  secretions 
of  affected  animals.    The  virus  of  the  wolf  is  said  to  be  first  in  order  of 
virulence,  that  of  the  cat  second,  that  of  the  dog  third.     Children  are 
more  susceptible  than  adults.    It  has  been  estimated  that  only  15   per 


HYDROPHOBIA  231 

cent  of  the  persons  bitten  take  the  infection.  The  disease  is  somewhat 
more  prevalent  in  the  hot  weather  of  summer,  but  it  may  be  encoun- 
tered at  any  season. 

Morbid  Anatomy. — The  lesions  are  found  almost  exclusively  in  the 
brain,  medulla,  and  cord,  but  are  not  specific  in  character.  There  may 
be  congestion  of  the  nerve  tissue,  with  perivascular  exudation  of  leuco- 
cytes and  minute  hemorrhages,  especially  in  the  medulla.  More  or  less 
extensive  hyperemia  of  the  mucous  membranes  of  the  respiratory  and 
digestive  tracts  may  be  found.  The  presence  of  the  virus  in  the  nerve 
tissues  may  be  demonstrated  by  the  inoculation  of  rabbits. 

Symptoms. — The  incubation  is  six  weeks  or  longer;  it  is  shorter  in 
children  than  in  adults.  The  more  extensive  the  wound  and  the  deeper 
the  penetration  of  the  tissues,  the  more  promptly  does  infection  occur. 
The  course  of  the  disease  may  be  studied  under  three  stages,  known  as 
the  initial  or  premonitory,  the  spasmodic,  and  the  paralytic. 

1.  Liitial  Stage. — A  feeling  of  numbness,  irritation,  or  pain  in  the  cica- 
trix of  the  wound  is  often  the  first  symptom.  The  patient  becomes 
morose,  melancholy,  depressed,  and  irritable ;  he  loses  his  appetite  and 
cannot  sleep.  He  is  particularly  sensitive  to  light  and  sound.  His 
voice  becomes  husky  and  he  has  difficulty  in  swallowing.  There  may 
be  slight  fever. 

2.  Spasmodic  Stage. — A  distinct  spasm  of  the  muscles  of  the  larynx 
and  mouth  develops  and  increases  the  difficulty  of  deglutition.  The 
spasm  is  provoked  by  efforts  to  swallow  or  by  anything  that  suggests 
it,  particularly  by  the  sound  of  running  water;  hence  the  fear  of  water 
(hydrophobia),  which  is  often  a  prominent  symptom.  Extreme  anxiety 
is  depicted  in  the  face  of  the  patient  and  a  sense  of  suffocation  adds  to 
his  suffering.  Maniacal  manifestations  are  frequently  engrafted  upon  the 
spasmodic  seizures,  during  which  peculiar  sounds  are  uttered  and  saliva 
is  sometimes  ejected,  but  the  patient's  mind  is  clear  in  the  interval 
and  he  frequently  converses  intelligently  in  regard  to  his  condition; 
he  may  even  express  fear  of  causing  injury  to  others.  There  is  rarely 
any  attempt  to  inflict  injury.  In  some  cases  the  temperature  remains 
normal  or  is  slightly  subnormal,  in  others  it  rises  to  102°  or  103°  F. 
(39.0° — 39-5°C.).  This  stage  usually  lasts  from  one  to  three  days,  but 
death  may  result  from  asphyxia  before  its  expiration. 

3.  Paralytic  Stage.— In  this  the  spasms  cease  and  the  patient  sinks 
into  a  state  of  unconsciousness;  the  heart  becomes  more  and  more 
feeble  until  death  supervenes. 

Pseudohydrophobia  (Lysophobia.)— This  is  a  neurotic  or  hysterical 
condition  in  which  the  symptoms  of  hydrophobia  are  simulated,  usually 
by  a  person  who  has  been  bitten  by  an  animal  supposed  to  be  rabid. 
It  may  develop  months  or  years  after  the  injury.  In  most  instances 
the  picture  is  overdrawn  and  there  is  a  display  of  dramatic  action  not 
seen  in  the  real  disease.  The  patient  believes  his  condition  serious  and 
so  declares  it.  Paroxysms  occur  in  which  he  grasps  at  his  throat  and 
asserts  his  fear  of  water  and  inability  to  swallow.  He  often  imitates 
the  sound  of  the  animal  and  foams  at  the  mouth.  The  condition  lasts 
longer  than  hydrophobia,  as  a  rule,  but  it  ends  in  recovery.  Death 
may  result,  however,  from  the  neurasthenic  condition,  which  is  usually 
the  predisposing  cause  of  the  attack. 


232  PRACTICE  OF  MEDICINE 

Diagnosis. — The  chief  difficulty  is  the  exclusion  of  pseuclohydrophobia. 
The  apparent  severity  of  the  symptoms  is  often  less  than  in  the  latter 
condition.  When  the  person  has  been  bitten,  the  animal  should  be  killed 
and  the  medulla  removed  for  investigation.  Subdural  inoculation  of  a 
rabbit  produces  the  disease  in  20  days.  When  this  is  not  practicable, 
the  animal  should  be  kept  in  comfortable  quarters  and  its  condition 
watched. 

Prognosis. — The  mortality,  as  stated  by  different  authorities,  varies 
from  40  to  80  per  cent.  When  the  disease  becomes  fully  developed  it  is 
almost  invariably  fatal. 

Prophylaxis. — Although  the  disease  is  uncommon  in  this  country,  it 
could  be  still  further  prevented,  as  in  England  and  Germany,  by  the 
muzzling  of  dogs  and  the  extermination  of  useless  curs.  Preventive 
inoculation  has  been  practiced,  particularly  in  France.  Pasteur  found 
that  by  passing  the  virus  through  successive  inoculations  in  rabbits  its 
virulence  was  so  increased  that  the  period  of  incubation  was  reduced  to 
seven  days.  Preservation  of  the  spinal  cords  of  these  rabbits  in  a  dry- 
ing-chamber for  from  12  to  15  days  progressively  reduced  the  virulence. 
After  testing  the  method  on  animals  he  applied  it  to  man,  using  on 
successive  days  a  stronger  virus  until  the  individual  became  immune 
even  to  the  virus  previously  inoculated  by  a  rabid  animal.  This  method 
is  still  employed,  but  notwithstanding  the  continued  favorable  reports, 
many  authorities  doubt  its  utility. 

Treatment. — The  wound  should  be  immediately  cleansed  and  thor- 
oughly cauterized  with  caustic  potash  or  pure  carbolic  acid,  and  treat- 
ed as  an  open  wound.  After  the  disease  has  developed,  nothing  can 
be  done  further  than  to  relieve  the  suffering.  The  room  should  be 
quiet,  moderately  dark,  and  free  from  drafts.  The  spasms  may  be  mod- 
erated by  morphin  hypodermically  or  chloroform  inhalation.  Milder 
remedies  are  useless.  A  cocain  spray  has  been  found  to  relieve  the 
spasm  and  sometimes  to  enable  the  patient  to  swallow.  When  this 
fails,  nourishment  must  be  given  by  the  rectum.  Treatment  with  the 
serum  of  animals  rendered  immune  has  proved  unsatisfactory,  except 
perhaps  in  animals  of  the  same  species. 

ANTHRAX. 

SPLENIC  FEVER,  CHARBON,  WOOL  SORTERS'  DISEASE,  RAC  PICKERS'  DISEASE. 

Definition. — An  acute  infectious  disease  caused  by  the  bacillus  anthra- 
cis,  in  some  cases  presenting  lesions  in  the  skin,  in  others  affecting  the 
internal  organs. 

Etio/ogy.—The  disease  is  very  prevalent  and  highly  fatal  among 
horses,  sheep,  and  cattle  in  some  localities.  It  is  much  less  common  in 
America  than  in  Europe  and  Asia.  It  is  communicated  to  man  by 
accidental  inoculation,  as  a  rule.  The  bacillus  is  one  of  the  most  familiar 
of  those  used  for  laboratory  experimentation  and  need  not  be  described. 
The  spread  of  the  disease  is  due  chiefly  to  the  remarkable  vitaHty  of 
the  spores,  which  are  capable  of  retaining  life  for  years  in  a  condition 
of  dryness  and  are  not  destroyed  by  a  temperature  of  212°  F.  (100° 
C.)  for  several  minutes.     The  victims  of  infection  are,  as  a  rule,  persons 


ANTHRAX  235 

whose  occupation  requires  them  to  come  into  contact  with  infected 
animals  or  to  handle  the  products  of  such  animals.  It  is  therefore  most 
frequently  seen  in  hostlers,  dairymen,  shepherds,  farmers,  butchers,  sorters 
of  hair  and  wool,  mattress-makers,  tanners,  and  furriers.  It  has  been 
produced  by  eating  the  meat  or  drinking  the  milk  of  diseased  cattle. 
The  inoculation  ordinarily  occurs  at  an  abraded  point  on  the  skin 
or  a  mucous  membrane,  but  may  result  from  the  inhalation  of  dust, 
particularly  that  from  infected  horsehair.  Insects  are  regarded  as 
possible  carriers  of  the  bacillus.  The  poison  cannot  penetrate  the  un- 
broken skin,  but  a  lesion  is  not  thought  to  be  necessary  when  the 
respiratory  or  intestinal  mucous  membrane  is  the  avenue  of  entrance. 

Symptoms. — The  incubation  does  not  exceed  three  days.  There  are 
two  principal  types  of  the  disease,  one  exhibiting  external,  and  the  other 
internal,  lesions. 

I.  External  Anthrax. — This  form  is  again  divided  into  two  kinds, 
malignant  pustule  and  malignant  edema. 

(^)  Maiignant  piistule  is  the  most  frequent  form  of  the  disease.  It 
is  seen  especially  on  the  hands,  neck,  and  face,  sometimes  on  the  lower  ex- 
tremity, as  a  result  of  direct  inoculation.  In  a  itV'j  hours,  or  not  until 
a  day  or  two,  after  inoculation,  a  burning  and  itching  sensation  is  felt. 
A  papule  develops  having  a  purple  center,  and  this  is  soon  converted 
into  a  vesicle  from  which  a  bloody  serum  is  discharged.  By  the  end  of 
36  hours  the  area  of  the  original  vesicle  is  converted  into  a  bluish  black 
necrotic  mass  which  is  usually  surrounded  by  a  hyperemic  zone  studded 
with  small  vesicles.  A  painful  lymphangitis  and  phlebitis  form  around 
this,  with  intense  swelling  of  the  tissues.  The  resulting  constitutional 
disturbances  are  generally  severe.  The  temperature  rises  rapidly,  often 
to  105°  F.  (40.5°  C),  and  there  are  usually  persistent  vomiting,  pro- 
fuse sweating,  and  great  weakness.  Delirium  sometimes  supervenes, 
but  the  mind  frequently  remains  clear.  Many  writers  refer  to  the  absence 
of  anxiety  on  the  part  of  the  patient,  even  when  his  condition  is  critical. 
The  temperature  sometimes  declines  and  becomes  subnormal,  while  the 
patient  sinks  into  a  collapse  that  usually  proves  fatal.  Death  often 
occurs  within  the  first  three  or  four  days.  When  the  symptoms  are  of 
only  moderate  severity,  recovery  is  possible.  The  pustule  sloughs  away 
and  the  wound  heals  by  granulation.  In  the  mildest  cases  the  swelling 
is  slight,  and  the  original  papule  dries  into  a  crust  that  separates  in 
the  course  of  a  few  days. 

(Ji)  Malignant  Edema. — This  is  seen,  for  the  most  part,  in  loose  con- 
nective tissue,  as  on  the  eylid,  lip,  neck,  forearm,  hand,  or  thigh,  some- 
times in  the  mucous  membrane  of  the  mouth  or  tongue.  No  papule  or 
vesicle  is  formed;  the  skin  may  not  be  reddened,  but  it  becomes  intensely 
edematous.  The  infiltration  rapidly  spreads;  bullae  sometimes  form 
upon  it  and  lead  to  gangrene  and  sloughing.  Intense  sepsis  develops, 
sometimes  preceding  the  local  manifestations. 

The  diagnosis  of  either  form  is  based  upon  the  appearances  described 
and  the  occupation  of  the  individual.  The  bacilli  may  be  found  in  the 
fluid  from  the  pustule  or  edematous  area,  and  later,  sometimes  only 
immediately  before  death,  in  the  blood. 

The  prognosis  is  especially  grave  when  the  pustules  are  situated  on 
the  head  or  neck.     The  mortality  is  then  25   per  cent;  when  the  lower 


234  PRACTICE  OF  MEDICINE 

extremity  is  affected,  it  is  5  per  cent.  The  edematous  form  is  inevitably 
fatal. 

2.  Internal  Anthrax. — There  are  also  two  kinds  of  internal  anthrax," 
designated  intestinal,  and  pulmonary  or  cerebral.  They  may  occur  in- 
dependently or  they  may  be  associated  with  malignant  pustule  or  ma- 
lignant edema. 

(a)  Intestinal  Anthrax. — This  type  was  formerly  known  as  mycosis 
intestinalis.  It  is  the  result  of  eating  the  meat  or  drinking  the  milk  of 
infected  cattle,  of  inhaling  and  swallowing  the  bacilli  from  different 
sources,  or  of  inoculation  of  the  mouth.  The  invasion  is  usually  acute, 
with  chill,  fever  often  reaching  106°  F.  (41.0°  C),  languor,  and  severe 
pain  in  the  head,  back,  and  legs.  Gastrointestinal  disturbances  soon 
follow,  especially  vomiting  and  diarrhea,  often  bloody  in  character. 
Dyspnea,  cyanosis,  and  great  restlessness  are  present.  Muscular  spasms 
or  convulsions  often  supervene.  There  may  be  hemorrhages  from  the 
mucous  membranes,  and  petechia  or  other  hemorrhagic  lesions  may 
be  found  in  the  skin  and  gums  or  other  mucous  membranes.  The  blood 
is  dark  and  slow  to  coagulate.  The  disease  always  terminates  fatally 
in  from  two  to  seven  days. 

QT)  Wool-Sorters'  Disease. — This  form  results  from  the  inhalation  or 
swallowing  of  dust  impregnated  with  the  bacilli  from  infected  wool  or 
hair,  often  after  it  has  been  imported  from  distant  countries.  There  is 
often  no  external  lesion.  The  onset  is  with  chill  and  great  prostration, 
pains  in  the  back  and  legs,  oppression  in  the  chest,  rapid  respiration, 
cough  and  dyspnea  or  a  sense  of  suffocation  (pulmonary  anthrax). 
The  fever  is  usually  moderate,  102°  to  103°  F.  (39.0°— 39.5°  C),  The 
pulse  becomes  rapid  and  feeble.  Violent  delirium  sometimes  develops. 
Bacilli  have  been  found  in  the  capillaries  of  the  brain  (cerebral  anthrax). 
In  less  severe  cases  there  may  be  diarrhea  and  other  symptoms  on  the 
part  of  the  alimentary  canal.  The  patient  soon  sinks  into  a  fatal  col- 
lapse. Tetanic  spasms  often  occur  shortly  before  death.  The  rag-picker's 
disease  is  usually  of  this  type. 

The  diagnosis  is  difficult  unless  the  probability  of  infection  is  known. 
The  occupation  of  the  patient  should  always  arouse  suspicion,  and  the 
bacilli  may  generally  be  found  in  the  sputum,  blood,  or  other  fluids  of 
the  body. 

Prognosis. — The  prognosis  of  anthrax  is  always  grave.  In  the  pus- 
tular form,  early  treatment  may  save  the  patient,  but,  after  general  sys- 
temic infection  has  occurred,  death  is  inevitable. 

Prophylaxis. — Theoretical  methods  of  prophylaxis,  involving  the  dis- 
infection of  wool  and  hair  and  the  use  of  antiseptic  solutions  by  the 
workmen,  are  difficult  of  application  among  the  classes  usually  affected. 
Diseased  animals  should  be  destroyed  and  their  carcasses  should  be 
burned.  Burial  is  unsafe.  Preventive  inoculation  of  animals  with  an 
attenuated  virus  has  been  practiced  in  France  with  much  success. 

Treatment. — This  is  for  the  most  part  surgical.  The  point  of  inocu- 
lation should  be  immediately  destroyed  with  nitric  acid,  carbolic  acid, 
or  the  actual  cautery.  The  entire  area  may  be  excised  early,  and  the 
resulting  wound  thoroughly  cauterized.  If  too  extensive,  the  area  may 
be  freely  incised  with  repeated  cross-cuts  and  treated  with  strong  caus- 
tics.   Subcutaneous  injections  of  carbolic  acid  into  the  surrounding  skin 


ACTINOMYCOSIS  235 

have  proved  successful  in  many  cases.  The  system  is  remarkably  toler- 
ant of  the  acid  in  this  disease;  15  grains  (i.o)  have  been  injected  in  a 
day.  The  application  of  very  hot  poultices  or  ice-bags  at  short  intervals 
seems  to  inhibit  the  growth  of  bacilli  in  the  superficial  tissues,  since  the 
more  resistant  spores  do  not  form  in  the  body.  Extensive  lesions 
should  be  treated  with  mercuric  chlorid  (i  :Soo)  and  covered  with  an 
ice-bag  or  poultice.  When  the  legs  are  edematous,  they  should  be  in- 
cised to  evacuate  the  poisonous  fluid.  In  the  internal  forms  of  the 
disease  we  can  only  hope  to  contribute  to  the  comfort  of  the  patient. 


ACTINOMYCOSIS. 

Definition. — A  chronic  infection  caused  by  the  streptothrix  actinomy- 
ces,  or  ray  fungus,  frequent  in  cattle,  but  rare  in  man. 

Etiology. — The  fungus  is  found  in  the  pus  from  the  affected  area,  in 
the  form  of  bright  yellow  granules  from  0.5  to  2.0  mm.  in  diameter. 
These  are  composed  of  masses  of  cocci  and  radiating  threads  with 
bulbous  extremities.  Several  atypical,  polymorphous  forms  of  the  ray 
fungus  have  been  recognized,  some  of  which  approach  very  closely  in 
morphology  to  the  bacilli.  Infection  generally  takes  place  in  the  skin 
directly  from  a  diseased  animal  or  in  the  mouth  through  eating  infected 
meat  or  cereals.  The  presence  of  such  lesion  as  a  carious  tooth  is  neces- 
sary to  the  entrance  of  the  fungus.  Men  are  more  exposed  to  infection, 
than  women. 

Morbid  Anatomy. — Granulomatous  tumors  are  formed  consisting  of 
lymphoid  and  epithelioid  cells  with  an  occasional  giant-cell.  These 
sometimes  disintegrate  to  form  abscesses,  but  they  do  not  involve  the 
neighboring  lymphatics. 

Symptoms. — The  disease  invades  the  alimentary  canal,  the  lungs,  the 
skin,  or  the  brain,  and  produces  symptoms  peculiar  to  each  location. 

1.  Alimentary  Canal. — The  jaw  is  usually  affected.  It  becomes  greatly 
swollen,  and  sinuses  burrow  from  it  into  the  face  and  neck.  The  tongue, 
intestine,  or  liver  may  be  involved  primarily  or  by  metastasis.  The 
fungus  has  been  found  in  a  diseased  appendix  and  in  a  pericecal  abscess. 

2.  The  Lungs. — Three  forms  of  pulmonary  actinomycosis  are  recog- 
nized: («;)  A  chronic  bronchitis  in  which  the  fungus  appears  in  the  spu- 
tum. (^)  A  miliary  form  in  which  nodular  masses  of  the  fungus  are 
surrounded  by  granulation  tissue,  resembling  miliary  tuberculosis,  (r) 
Extensively  destructive  lesions  causing  bronchopneumonia,  interstitial 
changes,  and  large  abscesses.  The  ribs,  sternum,  and  vertebra;  may  be 
eroded. 

3.  The  .S/^/;/.— Suppurating  nodules  are  formed  which  lead  to  extensive 
ulcers  and  fistulse  of  an  exceedingly  chronic  character. 

4.  The  Brain. — The  brain  may  be  involved  primarily  or  by  metastasis. 
Few  cases  have  been  observed.  The  symptoms  are  those  of  tumor  or 
abscess. 

All  forms  of  the  disease  are  accompanied  by  constitutional  disturb- 
ances of  a  septic  nature.  Persistent  cough  distinguishes  the  pulmonary 
form;  headache,  epilepsy,  or  other  symptoms  of  brain  tumor,  the  cerebral 
form.    Various  metastases  develop. 


236  PfL^CTICE  OF  MEDICINE 

The  diagnosis  depends  upon  the  discover}-  of  the  fungus,  which  is 
readily  recognized. 

Prognosis. — Cases  that  are,  within  the  reach  of  surgery  may  recover. 
The  internal  forms  of  the  disease  are  generally  fatal. 

Treatment. — The  surgical  treatment  consists  chiefly  in  the  incision 
and  thorough  evacuation  of  abscesses  and  the  removal  of  diseased  bone 
and  other  tissues.  Potassium  iodid,  gr.  Ix  (3.88),  daily  has  been  rec- 
ommended as  curative  in  internal  cases.  It  should  not  be  relied  upon 
to  the  exclusion  of  surgical  measures. 

PSITTACOSIS. 

Definition. — An  acute  infectious  disease  of  birds,  which,  when  con- 
tracted by  man,  produces  lesions  in  the  respiratory  organs,  with  fever 
and  other  manifestations  of  toxemia. 

Etiology. — The  disease  has  been  studied  especially  in  Paris,  where  it 
was  introduced  in  1892  by  a  cargo  of  parrots  and  parrakeets.  The 
bacillus  of  Nocard  is  believed  to  be  the  specific  cause.  This  is  a  rapidly 
motile  rod  having  from  8  to  12  cilia.  It  belongs  to  the  paratyphoid 
or  paracolon  group.  It  differs  from  the  colon  bacillus,  and  at  the  same 
time  resembles  the  typhoid,  in  being  more  virulent,  actively  motile,  in  not 
fermenting  lactose  or  coagulating  milk,  and  not  producing  indol.  It 
differs  from  the  typhoid  and  resembles  the  colon  in  its  growth  on  gelatin 
and  potato  or  upon  old  cultures  of  the  typhoid  bacillus.  The  disease 
is  communicated  directly  from  the  bird,  by  the  feathers,  cage,  or  other 
articles  soiled  with  the  dejections,  less  frequently  from  another  individual. 

Morbid  Anatomy. — The  lesions  are  in  the  beginning  those  of  bronchial 
catarrh,  occasionally  accompanied  with  a  membranous  formation  like 
that  of  diphtheria  in  appearance.  Later  there  is  the  formation  of  iso- 
lated areas  of  consolidation  in  both  lungs  like  those  of  bronchopneu- 
monia. 

Symptoms. — The  incubation  is  probably  from  7  to  12  days.  The  in- 
vasion is  preceded  by  malaise,  headache,  pains  in  the  back  and  limbs, 
sometimes  by  epistaxis,  nausea,  and  vomiting.  Constipation  is  usually 
present,  occasionally  diarrhea.  The  onset  is  often  sudden  with  a  chill 
or  chilly  sensations  and  rapid  rise  of  fever,  reaching  103°  or  104°  F. 
(39.5°  or  40.0°  C.)  on  the  second  day,  and  profound  prostration.  The 
pulse  is  accelerated.  The  fever  subsides  on  the  fourth  or  fifth  day,  and 
there  is  an  afebrile  period  of  variable  duration.  This  is  followed  by  a 
return  of  the  fever,  and  this  in  turn  by  an  afebrile  period.  Thus  the 
disease  continues  sometimes  for  15  or  20  days.  The  last  defervescence 
lasts  two  or  three  days.  The  physical  signs  are  those  of  broncho- 
pneumonia. Delirium,  usually  mild,  occasionally  violent,  may  be  present. 
The  spleen  is  slightly  enlarged,  and  febrile  albuminuria  is  present.  The 
course  of  the  disease  is  like  that  of  relapsing  fever,  but  the  relapses 
are  attributed  to  the  involvement  of  additional  areas  of  the  lungs. 

Prognosis. — The  mortality  varied  in  the  cases  recorded  between  20 
and  40  per  cent. 

Treatment. — The  patient  should  be  isolated  in  a  well-ventilated  room 
to  prevent  spread   of  the   infection.     The  treatment  is   wholly   sympto- 


FOOT-AND-MOUTH  DISEASE  237 

matic.  The  strength  is  to  be  maintained  by  nutritious  Hquid  diet  and 
free  stimulation.  Cold  baths  or  sponging  is  recommended  for  the  re- 
duction of  the  temperature. 

MILK  SICKNESS. 

Definiiion. — An  infectious  disease  of  man  and  cattle,  characterized  by 
constipation  and  severe  nervous  phenomena.  It  was  formerly  prevalent 
west  of  the  AUeghanies.    In  cattle  it  is  known  as  "the  trembles." 

Etiology. — The  specific  cause  is  unknown.  It  is  supposed  to  reside 
in  the  earth,  since  the  disease  has  almost  entirely  disappeared  with  the 
clearing  of  the  forests.  The  milk  and  flesh  of  affected  cattle  are  ex- 
tremely poisonous  to  other  animals,  hence  it  is  believed  that  meat,  milk, 
butter,  and  cheese  are  the  chief  carriers  of  infection  to  man.  Adult  males 
are  most  frequently  affected. 

Symptoms. — The  incubation  is  short  and  characterized  by  malaise, 
headache,  and  indigestion,  followed  by  burning  pain  in  the  stomach 
and  vomiting.  There  is  slight  fever,  great  thirst,  and  usually  obstinate 
constipation.  The  tongue  becomes  dry  and  swollen  and  the  breath  has 
a  characteristically  fetid  odor.  A  typhoid  state  sometimes  supervenes, 
with  great  restlessness,  irritability,  sometimes  delirium,  which  may  termi- 
nate fatally  in  convulsions  or  coma.  The  duration  of  illness  is  variable. 
Death  may  occur  in  two  or  three  days,  or  after  three  or  four  weeks. 

Diagnosis. — The  diagnosis  is  made  with  difficult}^,  especially  the  ex- 
clusion of  ptomain  and  fungus  poisoning,  unless  the  source  of  infection 
can  be  traced  to  cattle  having  the  trembles. 

Treatment. — This  is  purely  symptomatic.  The  constipation  should 
be  promptly  overcome  in  order  to  eliminate  the  poison.  Stimulants  are 
indicated. 

FOOT-AND-MOUTH  DISEASE. 

EPIDEMIC  STOMATITIS,  APHTHOUS  FEVER. 

Definition. — A  highly  virulent,  febrile  disease  of  cattle,  occasionally  con- 
tracted by  man  in  the  form  of  a  vesicular  eruption  of  the  mouth  or  a 
miliary,  sometimes  pustular  eruption  of  the  hands. 

Etiology. — The  disease  is  most  frequent  in  cattle,  sheep,  goats,  and 
swine.  Among  cattle  it  has  been  especially  severe  in  Texas.  It  is  con- 
tracted by  those  who  work  with  the  diseased  animals,  especially  by 
milkers,  but  sometimes  also  through  drinking  the  milk  or  eating  the  but- 
ter from  the  affected  cows.  It  is  believed  to  be  caused  by  an  exceedingly 
small  micro-organism. 

Symptoms. — After  an  incubation  of  four  or  five  days,  the  disease  be- 
gins by  a  more  or  less  distinct  chill,  with  fever,  and  followed  by  prostra- 
tion. Vesicles  similar  to  those  of  aphthous  stomatitis  soon  form  upon 
the  mucous  membrane  of  the  mouth,  including  the  tongue  and  lips,  and 
often  upon  the  pharynx.  All  the  associated  symptoms  of  the  latter  dis- 
ease, including  redness,  heat,  and  pain,  are  present,  and  the  flow  of 
saliva  is  greatly  increased.  The  hands  and  fingers  usually  show  a  papu- 
lar  or  pustular  eruption. 


2sS  PRACTICE  OF  MEDICINE 

Diagnosis. — The  disease  is  usually  recognized  without  difficulty,  owing 
to  the  prevalence  of  the  affection  among  cattle  in  the  vicinity. 

Prognosis. — Recovery  within  a  week  or  ten  days  is  the  rule,  but  fatal 
cases  have  been  reported, 

Treamenf. — A  serum  produced  by  Loffler  seems  to  be  protective  to 
animals.  The  best  means  of  protecting  human  beings  are  the  thorough 
boiling  of  the  milk  and  the  use  of  antiseptics  by  those  having  to  come 
into  contact  with  diseased  cattle.  The  disease  of  the  mouth  should  be 
treated  as  an  ordinary  aphthous  stomatitis. 


Practice  of  Medicine— French. 


PLATE  V. 


40 


45 


50 


42 


43 


46 


47 


48 


H^ 


Vw 


..i>^ 


51 

^   -Pi 


53 


53 


\, 


©-. 


54 


55 


THE  PARASITES  OF  MALARIA. 

(Marchiafava  and  Bigftami  in  "  Twentieth  Century  Practice.") 


EXPLANATION  OF  PLATE  V. 

Figs.  1-14. — The  hematozoa  of  Quartan  Fever;  Figs.  1-9,  Progressive  endo- 
globular  development  of  the  quartan  parasite;  Figs.  10  and  11,  Endoglobular 
fission  forms;  Fig.  12,  Free  sporulation ;  Figs.  13  and  14,  Free  pigmented 
forms,  one  flagellated. 

Figs.  15—33. — Hematozoa  of  Tertian  Fever:  Figs.  15-24,  Progressive  en- 
doglobular development  of  the  tertian  parasite  ;  Figs.  25-27,  Endoglobular  fission 
forms;  Figs.  2S-30,  Free  sporulation;  Figs.  31-33,  Free  pigmented  forms,  one 
flagellated. 

Figs.  34-55. — Hematozoa  of  Estivo-autumnal  (quotidian)  Fever;  Figs. 
34-50,  Endoglobular  development  of  the  quotidian  parasite;  Figs.  42,  48  and 
49,  parasites  in  altered  red  blood  corpuscles  (brassy  bodies) ;  Figs.  51-55,  en- 
doglobular forms  in  sporulation. 


SECTION  II. 
Diseases  Due  to  Animal  Parasites. 


PROTOZOAN  DISEASES. 


MALARIA. 


INTERMITTENT    FEVER,    CHILLS   AND    FEVER,    FEVER    AND    AGUE,    SWAMP 

FEVER,   PALUDISM. 

Definiiion. — Infection  by  the  plasmodium  malariae  of  Laveran,  wdth 
the  production  of  a  febrile  disease,  of  which  the  following  are  the  princi- 
pal forms :  (<?)  Intermittent  fever,  in  which  there  are  paroxysms  of 
chill,  fever,  and  sweating  at  regular  periods;  (^b^  estivo-autumnal  fever, 
a  continued,  remittent  fever;  (f)  pernicious,  rapidly  fatal  forms;  and 
(i^)  a  malarial  cachexia,  a  chronic  form  showing  profound  anemia  and 
enlargement  of  the  spleen. 

Etiology. — i.  The  plasmodium  malariae,  discovered  by  Laveran  in 
1880,  is  the  specific  cause.  2.  The  only  demonstrated  means  by  which 
the  infection  is  produced  in  man  is  through  inoculation  by  the  mosquito. 
Egbert,  of  Honduras,  maintains  that  fleas  may  also  introduce  the  par- 
asite, since  he  has  observed  the  disease  in  localities  where  this  insect  is 
abundant  and  mosquitoes  unknown. 

The  Parasite. — The  plasmodium  is  a  motile,  protozoan  parasite  belong- 
ing to  the  hematozoa,  or  hemocytozoa  (Thayer).  Our  knowledge  of  it 
is  limited  almost  entirely  to  the  phenomena  which  occur  within  the 
human  body  and  that  of  the  mosquito.  Attempts  to  cultivate  it  in 
artificial  media  have  failed.  It  is  regarded  as  asexual  in  man,  but  it  is 
believed  to  attain  sexual  maturity  in  the  mosquito.  The  cycle  of  its 
existence  is  probably  completed  in  the  water  of  swamps  and  stagnant 
pools,  which  are  at  the  same  time  the  birthplace  and  grave  of  the  mos- 
quito. Similar  protozoan  forms  have  been  found  in  the  red  blood  cor- 
puscles of  fish,  turtles,  snakes,  and  birds  inhabiting  the  same  regions. 

Three  forms  or  species  of  the  plasmodium  have  been  recognized  :  (i) 
The  parasite  of  tertian  fever,  (2)  the  parasite  of  quartan  fever,  and 
(3)  the  parasite  of  estivo-autumnal  fever.  All  of  these  present  different 
appearances  peculiar  to  stages  in  their  development.     (See  Plate  V.) 

The  Tertian  Parasite. — The  young  parasite  enters  the  red  blood-cor- 
puscle in  the  form  of  a  small,  nucleated,  hyaline,  ameboid  bouy  As  it 
grows  it  almost  completely  fills  the  corpuscle.  At  the  expense  of  the 
hemoglobin  of  the  cell,  it  accumulates  pigment  which  may  be  seen  as 
small,  dark  granules  in  active  motion  within  it,  but  ultimately  becoming 
collected  into  a  close  mass,  usually  near  the  center  of  the  parasite.    As 


240  PRACTICE  OF  MEDICINE 

a  result  of  this  action,  the  blood-corpuscle  becomes  decolorized  and  ex- 
pands to  accommodate  the  increasing  size  of  the  plasraodium.  A  process 
of  sporulation  now  takes  place.  The  protoplasm  of  the  ameba  becomes 
opaque,  and  soon  radial  striations  may  be  seen  extending  inward  from 
the  periphery  nearly  or  quite  to  the  mass  of  pigment  at  the  center. 
The  original  parasite  is  thus  divided  into  from  12  to  20  small  segments, 
each  of  which  is  destined  to  become  a  young  plasmodium.  The  envelop- 
ing red  blood-corpuscle  has  been  destroyed  by  this  time  and  the  young 
parasites  are  set  free  in  the  blood.  One  of  the  most  remarkable  features 
is  that  the  parasites  of  the  same  group  or  family  all  mature  at  the  same 
time,  and  thus  give  the  characteristic  periodicity  to  the  clinical  mani- 
festations. The  cycle  of  the  tertian  parasite  within  the  human  being  is 
completed  in  48  hours,  hence  the  paroxysms  occur  at  regular  intervals 
of  this  length,  or  on  alternating  days.  It  not  infrequently  happens  that 
two  groups  of  the  same  parasite  are  present  at  the  same  time,  one 
maturing  every  day  and  producing  a  quotidian  t3^pe  of  the  disease. 

Tfie  Quartan  Farasite.—TMvs,  is  very  similar  to  the  tertian,  but  it  is 
somewhat  smaller,  less  active,  and  the  pigment  which  it  accumulates  is 
usually  more  abundant  and  darker  in  color.  The  blood-corpuscle,  in- 
stead of  expanding,  appears  shrunken  around  it  and  acquires  a  greenish 
shade.  In  the  process  of  sporulation,  onl}^  from  5  to  10  segments  are 
formed,  and  these  usually  collect  around  the  pigment  mass  in  the  form  of 
a  rosette.  Their  cycle  is  of  72  hours'  duration.  When  only  a  single 
group  is  present,  the  paroxysms  occur  on  every  fourth  day ;  when  there 
are  two  groups,  the  paroxysms  occur  on  two  succeeding  days,  followed 
by  an  interval  of  one  day.  More  than  two.  generations  with  correspond- 
ing irregularity  of  clinical  manifestations  are  sometimes  observed. 

The  Estivo-Autumnal  I'amsite.— This  parasite  is  described  under  two 
forms  :  (a)  The  quotidian  estivo-autumnal  parasite,  and  (/;)  the  malig- 
nant tertian  estivo-autumnal  parasite.  Each  of  these  appears  at  first  as 
a  small,  hyaline  body,  smaller  than  that  of  the  tertian  parasite,  then  as  a 
pigmented  body,  and  later  as  a  segmenting  body.  Crescentic,  ovoid,  and 
flagellate  bodies  also  appear  later.  (See  Plate  VI.)  Marchiafava  con- 
siders them  the  beginning  of  a  life  cycle  which  is  completed  in  the  mos- 
quito. The  flagellate  forms  may  be  seen  also  in  connection  with  the 
tertian  and  quartan  parasites  and  is  believed  to  be  concerned  in  the 
process  of  reproduction. 

J^Aag-ocjtes.— The  liberation  of  segments  gives  rise  to  an  energetic 
phagocytosis.  The  polynuclear  neutrophile  cells  attack  and  devour  with 
great  activity  the  segments,  flagella,  pigment,  and  fragments  of  the 
disintegrated  corpuscles.  A  single  phagocyte  may  envelop  several  para- 
sites. 

The  Mosquito.— So  far  as  is  now  known,  the  plasmodium  undergoes 
development  only  in  the  species  of  the  mosquito  belonging  to  the  genus 
Anopheles.  Of  these  there  are  two  varieties  :  (a}  Anopheles  claviger  and 
A.  pictus,  recognized  by  the  yellow  color  of  their  bodies  and  spotted 
wings;  and  (^)  Anopheles  bifurcatus  and  A.  nigripes,  smaller,  dark  brown 
or  brownish  yellow  insects  without  spots  on  the  wings.  The  anopheles 
alight  with  the  body,  proboscis,  thorax,  and  abdomen  in  a  straight  line 
and  often  perpendicular  to  the  surface  upon  which  they  rest.  It  is  only 
the  female,  especially  the  A.  claviger,  that  transports  the  plasmodium; 


PLATE  VI. 

STAINED    INTRACORPUSCULAR  AND    CRESCENTIC    FORMS 
OF    THE    ESTIVO-AUTUMNAL    PARASITES. 

Note  the  polar  staining  of  the  crescents,  the  irregular  staining  of  the 
protoplasm,  and  the  eosin-stained  border.  Some  of  the  crescents  have  lost 
the  eosin-stained  rim  and  stain  almost  uniformly  throughout. 


Practice  of   Medicine, — French, 


Plate  VI. 


0 


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0 


5 


24. 


ft  r 


Ciaiff,  Del. 


Stained   forms  of  the   Estivoautumnal    Parasites,— Crc?/^, 


MALARIA 


241 


the  male  is  vegetarian  in  his  diet.  After  the  female  has  filled  herself 
with  blood,  she  flies  to  a  dark,  sheltered  place,  near  stagnant  water. 
After  about  six  days  she  alights  upon  the  water  and  deposits  her  eggs. 
She  commonly  dies  in  the  water  beside  the  eggs.  These  are  oval  and 
float  with  their  ends  in  contact.  The  young  larvae  often  devour  the 
body  of  their  dead  parent  in  their  search  for  nutriment.  From  the 
larval  stage  they  pass  into  the  nymphal,  during  which  they  float  upon 
the  water.  It  is  distinctive  of  the  class  that  they  do  not  sink  below  the 
surface  (Fig.  17).  Finally  the  shell  cracks  and  the  young  mosquito  is 
liberated.  Manson  believes  that  the  larva  is  infected  by  eating  the 
body  of  the  mother.  The  cycle  of  the  Plasmodium's  development  within 
the  mosquito  is  well  illustrated  in  Plate  VII. 

It  is  only  since  these  facts  have  been  discovered  that  a  proper  esti- 
mate can  be  placed  upon  the  various  theories  that  have  been  held  here- 
tofore in  regard  to  the  causes  of  malaria.  All  the  geographic,  seasonal, 
and  telluric  influences  which  have  been  regarded  as  especially  favorable 
to  the  production  of  the  disease  may  now  be  summed  up  in  the  single 
statement  that  all  conditions  which  favor  the  propagation  and  activity 
of  the  anopheles  are 
favorable  to  malaria. 
\'\Tiere  mosquitoes  do 
not  exist,  there  is  no 
malaria.  The  presence 
of  the  anopheles  does 
not  invariably  signify 
a  danger  of  malarial 
infection,  however,  for 
Nuttall  and  others 
have  shown  that  the 
disease  has  disap- 
peared from  districts 
in  England  formerly 
malarious,  although 
the  anopheles  and  swamps  remain.  Occasional  cases  are  attributed  to 
the  transfer  of  infection  by  the  mosquito  to  healthy  persons,  from  others 
who  come  to  the  region  while  infected. 

Marshes  in  which  there  is  an  abundance  of  decaying  vegetable  matter 
are  especially  favorable  to  the  production  of  malaria.  The  turning  up  of 
soil  by  plowing  has  frequently  been  followed  by  the  appearance  of  the 
disease  in  the  vicinity,  possibly,  as  has  been  suggested,  on  account  of 
permitting  the  formation  of  small  pools  to  serve  as  the  breeding-places 
of  mosquitoes.  The  fact  that  persons  living  in  the  lower  stories  of 
dwellings  are  more  frequently  attacked  than  those  on  the  upper  floors  is 
explained  by  the  low  flight  of  the  insect.  The  same  fact  accounts  for  the 
absence  of  the  disease  at  high  altitudes  and  on  mountain-tops.  The 
influence  of  season,  of  winds,  forest  trees,  and  the  danger  of  night  air 
are  all  apparent.  High  temperature  favors  the  production  of  the  disease, 
but  the  drying  of  swamps  checks  it  for  a  time.  A.  F.  A,  King  has 
recently  advanced  the  theory  that  bright  sunlight  is  of  greater  im- 
portance than  heat,  especially  in  the  life  cycle  of  the  plasmodium  after 
it  has  entered  the  blood. 
16 


Fig. 
water. 


17. — Position    of   anopheles   larvae   at   surface    of 
(After  Howard,  Bulletin  U.  S.  Dept.  of  Agriculture.) 


242  PRACTICE  OF  MEDICINE 

In  the  United  States,  the  malarial  districts  are  found  especially  along 
the  southern  Atlantic  and  Gulf  coasts  and  up  the  Mississippi  and  its 
larger  tributaries.  But  the  disease  is  much  less  prevalent  than  it  was  a 
half-century  ago,  chiefly,  perhaps,  on  account  of  the  redemption  of  swamp 
lands  for  the  purposes  of  agriculture.  It  is  more  common  in  the  countr}' 
than  in  cities.  Its  virulence  is  much  greater  in  the  tropics  and  in  sub- 
tropical climates  than  further  north. 

Age,  sex,  and  other  individual  peculiarities  are  unimportant,  since 
exposure  is  the  principal  feature,  and  very  few  persons  are  immune  to 
either  the  mosquito  or  the  plasmodium.  The  negro  is  not  so  susceptible 
as  the  Caucasian.  King  explains  this  on  the  supposition  that  the 
negro's  dark  skin  prevents  the  penetration  of  light  to  the  interior  of 
the  body  and  thus  inhibits  the  sporulation  of  the  plasmodium.  Men 
are  five  or  six  times  more  frequently  affected  than  women,  on  account 
of  greater  exposure.  It  has  been  asserted  that  the  anopheles  rarely 
enter  dwelling-houses. 

Morbid  Anaiomy. — We  know  little  of  the  lesions  produced  by  the 
milder  forms  of  malaria,  for  they  are  seldom  fatal.  In  severe  or  pro- 
tracted cases,  the  blood  become^  anemic,  the  spleen  is  enlarged,  and 
spontaneous  or  traumatic  rupture  has  been  observed.  In  fatal  pernicious 
forms  of  the  disease,  and  after  the  malarial  cachexia,  the  changes  are  in 
part  a  result  of  the  alterations  of  the  blood,  and  in  part,  doubtless,  a 
result  of  the  formation  of  toxins. 

Pernicious  Malaria. — The  blood  is  hydremic,  the  red  corpuscles  are 
pale,  and  the  serum  is  often  tinged  with  hemoglobin.  Red  corpuscles 
containing  the  parasites  may  be  found  in  the  blood-vessels  of  all  parts 
of  the  body,  particularly  in  the  spleen,  bone  marrow,  and  brain.  Extra- 
cellular parasites  are  also  found  in  great  numbers.  Along  with  these 
forms,  numerous  phagocytes  are  seen  everywhere;  they  sometimes  form 
an  almost  complete  occlusion  of  the  arterioles,  especially  in  the  liver  and 
brain.  Pigmentation  is  almost  universal,  but  becomes  extreme  in  the 
spleen  and  brain,  affecting  moderately  also  the  kidneys.  Areas  of  necro- 
sis may  be  seen  in  the  liver  and  elsewhere,  especially  in  the  estivo- 
autumnal  form.  Small  punctate  hemorrhages  may  be  found  in  the  same 
regions.  The  spleen  is  enlarged  to  a  variable  degree ;  in  recent  cases  it 
is  soft;  after  repeated  attacks  it  becomes  firm  (ague  cake).  The  liver  is 
moderately  enlarged,  and  capillary  thromboses  have  been  found  in  it. 
The  kidneys  show  cloudy  swelling  or  fatty  degeneration ;  and  after  severe 
hematuria,  there  is  often  hemorrhage  into  the  glomeruli  and  necrosis  of 
the  tubular  epithelium. 

Malarial  Cachexia. — Death  is  usually  a  result  of  anemia  or  hemor- 
rhage. All  the  organs  are  found  anemic.  The  pigmentation  is  general, 
but  the  coloring  matter  is  deposited  around  the  blood-vessels  and  in  the 
spleen  along  the  trabeculae.  It  is  found  also  in  the  peritoneum,  around 
the  blood-vessels  of  the  mucous  membranes  of  the  stomach  and  intes- 
tines, and  between  the  gland-cells  of  Peyer's  patches.  The  spleen  may 
weigh  8  or  lo  pounds.  It  is  dense  and  the  cut  surface  has  a  uniform  or 
mottled  brown  color.  Enlargement  and  pigmentation  of  the  liver  and 
kidneys  are  also  com.mon.    The  liver  may  become  sclerotic. 

Clinical  Forms  of  Malaria.— i.  Tertian  intermittent  fever  is  due  to  a 
parasite  which  matures  and  gives  rise  to  a  paroxysm  every   48  hours. 


EXPLANATION   OF   PLATE  VII. 

Figs.  i-io. — D.evelopment  of  crescents  in  the  Middle  Intestine  of  the 
Anopheles  claviger  ;  Fig.  i,  Crescent  in  the  wall  of  the  middle  intestine  a  little 
less  than  two  days  after  the  Anopheles  has  sucked  the  blood  of  a  sufferer  from 
malaria.  The  parasite  preserves  its  spindle  shape,  resembling  perfectly  the 
form  which  it  may  assume  in  the  blood  of  man.  Figs.  2-5,  Forms  of  progres- 
sive development,  surrounded  by  a  very  thin  hyalin  capsule,  showing  phases  of 
successive  division  of  the  nucleus.  The  nuclei  of  the  parasitic  body  in  Fig.  5 
are  small  and  very  numerous ;  Fig.  6,  Forms  of  complete  development  of  the 
crescenting  sporozoon.  Within  the  capsule  are  seen  numerous  sporozoites. 
Fig  6  is  from  the  infected  intestine  of  the  Anopheles  cut  171  toto,  after  being  em- 
bedded in  parafin ;  Fig.  7,  A  mature  sporozoon  containing  a  large  number  of 
sporozoites,  seen  in  an  unstained  fresh  specimen ;  Fig.  8,  Salivary  gland  of 
Anopheles,  the  cells  of  W'hich  contain  numerous  sporozoites;  Fig.  9,  Mature 
sporozoites ;  Fig.  10,  A  large  capsule  containing  many  brown  bodies  of  varying 
form  and  structure. 

Figs.  11-18. — Developmental  forms  of  the  parasites  of  ordinary  tertian  in 
the  middle  intestine  of  the  Anopheles  claviger;  Fig.  11,  Tertian  bodies  in  the 
substance  of  the  middle  intestine  less  than  two  days  after  the  insect  had  sucked 
the  blood  of  a  patient  with  tertian  fever;  Figs.  12-16,  Later  developmental  forms 
of  the  tertian  sporozoon,  showing  successive  division  of  the  nucleus  of  the  para- 
site;  Fig.  17,  Mature  tertian  sporozoon  containing  numerous  sporozoites  and 
the  residua  of  segmentation  (semi-schematic) ;  Fig.  18,  Mature  tertian  sporozoon 
containing  many  sporozoites  and  residua  of  segmentation,  seen  in  an  unstained 
fresh  preparation. 

Fig.  19. — The  middle  intestine  of  a  specimen  of  Anopheles  claviger  cap- 
tured in  a  cabin  in  Ostia  (a  region  where  grave  malaria  prevails),  occupied  by 
several  peasants  suffering  from  malaria.  It  contains  an  enormous  quantity  of 
cystic  bodies,  the  greater  number  of  them  mature  and  enclosing  sporozoites. 
They  are  scattered  throughout  the  entire  length  of  the  middle  intestine,  but  are 
more  numerous  in  the  middle  third.     The  figure  is  semi-schematic. 


Practice  of  Medicine.— French. 


PLATE  VII. 


MALARIA    PARASITE   IN    THE    MOSQUITO. 

{Marchia/avaand Bigtiami,  in  "Twentieth  Century  Practice."^ 


MALARIA  243 

When  two  groups  of  these  parasites  are  present,  one  group  matures  every 
day,  causing  a  paroxysm  every  24  hours.  The  disease  is  then  known  as 
double  tertian  or  quotidian  (daily)  intermittent  fever.  This  is  the 
most  prevalent  type  of  intermittent  fever  in  many  regions.  Other  forms 
are  rarely  seen  in  the  Philippine  Islands. 

2.  Quartan  Intermittent  Fever.— The  parasite  causing  this  type  of  the 
disease  matures  in  7  2  hours.  Three  kinds  of  infection  are  recognized — 
single,  double,  and  triple.  In  the  single  form  there  is  a  paroxysm  on  the 
first  and  one  on  the  fourth  day.  In  the  double  form  there  is  a  paroxysm 
on  the  first  day,  none  on  the  second,  one  on  the  third,  and  one  on  the 
fourth.  In  the  triple  quartan  three  groups  of  the  parasites  mature  on 
different  days,  producing  a  paroxysm  every  day,  or  a  quotidian  quartan 
intermittent  fever.  This  form  is  usually  recognizable  by  the  very  unequal 
intensity  of  the  paroxysms. 

3.  Estivo-Autumnal  Fever. — This  name  is  sufificiently  appropriate  in 
our  country,  where  the  disease  prevails  almost  exclusively  during  the 
summer  and  autumn;  but  in  many  other  regions,  especially  in  tropical 
and  subtropical  climates,  it  is  a  perennial  disease.  Two  forms  are  recog- 
nized, a  quotidian  and  a  tertian.  Some  writers  have  maintained  that 
the  former  is  a  double  tertian,  but  the  more  prevalent  view  refers  them 
to  different  plasmodia,  one  maturing  in  24  hours,  the  other  in  48.  This 
type  of  the  disease  differs  from  the  intermittent  chiefly  in  the  greater 
length  of  the  paroxysm  and  relative  brevity  of  the  interval.  It  also  shows 
a  tendency  to  become  remittent,  the  intermissions  often  becoming  incom- 
plete. As  a  rule,  it  is  of  much  greater  severity.  It  is  only  in  this  type  of 
malaria  that  crescents  are  found  in  the  blood.  The  term  pernicious  re- 
mittent fever  is  applied  to  the  disease  when  such  grave  symptoms  as  hema- 
turia, coma,  severe  gastrointestinal   disturbances,  and  jaundice  appear. 

4.  Remittent  Fever.— This  form  is  attributed  to  the  sporulation  of 
more  than  one  group  of  estivo-autumnal  parasites  at  irregular  intervals 
or  to  the  presence  of  two  or  more  different  species.  It  may  begin  with 
an  intermittent  type  of  fever,  but  the  intermissions  soon  disappear,  and 
the  pyrexia  becomes  continuous,  with  more  or  less  marked  remissions. 
Hyperpyrexia  is  not  unusual. 

5.  Malarial  Cachexia,  or  Chronic  Malaria.— This  may  result  from  the 
frequent  repetition  or  long  duration  of  any  of  the  other  forms  of  mala- 
rial infection.  There  may  be  no  parasites  in  the  blood.  The  fever  is 
very  irregular  or  it  may  be  absent.  The  spleen  becomes  much  enlarged. 
The  blood  is  extremely  anemic  and  contains  much  pigment. 

Symptoms. — The  period  of  incubation  is  generally  stated  as  from  a 
few  hours  to  several  months.  In  the  few  instances  in  which  the  inocula- 
tion by  the  mosquito  has  been  watched,  the  period  varied  from  16  to  19 
days  in  the  intermittent  form  and  from  9  to  12  days  in  the  estivo- 
autumnal.  It  is  believed  to  be  longest  in  the  quartan  and  shortest  in 
the  remittent.  A  gradually  increasing  interval  often  occurs  between 
attacks  of  the  disease,  which  is  attributed  to  the  development  of  a  sys- 
temic or  therapeutic  immunity. 

Of  the  different  forms  as  they  are  observed  in  America,  the  tertian  is 
the  most  frequent;  the  double  tertian  is  probably  more  frequent  than  the 
single.  The  estivo-autumnal  is  often  seen,  but  the  quartan  is  rare.  The 
estivo-autumnal  is  the  most  virulent,  particularly  in  the  tropics. 


244 


PRACTICE  OF  MEDICINE 


Prodromal  symptoms  are  usually  felt.  The  individual  who  has  previ- 
ously suffered  from  the  disease  can  generally  predict  the  approach  of  a 
paroxysm,  from  a  feeling  of  lassitude,  headache,  pain  in  the  extremities, 
often  accompanied  by  yawning  and  stretching.  Nausea  and  vomiting 
may  occur;  bronchitis  is  often  present.  In  fully  two-thirds  of  the  cases 
the  paroxysms  occur  before  noon ;  they  are  almost  never  seen  at  night. 

I.  Symptoms  of  Intermittent  lever.— The  paroxysms,  whether  tertian, 
quartan,  or  quotidian  with  reference  to  periodicity,  are  all  of  the  same 
character.  The  typical  paroxysm  lasts  from  8  to  1 2  hours  and  consists 
of  a  chill,  fever,  and  sweating.  It  is  thus  divided  into  three  periods, 
known  as  the  cold,  the  hot,  and  the  sweating  stages. 


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Fig.  18.— Quotidian  fever.     (Se.guin.) 


Fig.  19.— Tertian  fever.     (Seguin.) 


I.  T/ie  Cold  Stage.— Th^  chill  is  usually  severe  and  lasts  from  15  to 
45  minutes.  The  shivering  involves  the  entire  body,  and  the  teeth 
chatter.  The  temperature  of  the  skin  is  reduced.  The  face  and  hands, 
often  the  entire  body,  become  cyanotic,  and  the  patient  complains  of 
intense  cold,  notwithstanding  the  warmest  coverings.  The  general  tem- 
perature is,  however,  increased  during  the  chill,  often  reaching  104°  to 
106°  F.  (40.0°— 41.0°  C).  The  pulse  is  rapid  and  of  high  tension.  The 
feeling  of  coldness  may  continue  for  a  time  after  the  rigor  has  ceased. 
Rarely,  the  chill  is  omitted— "  dumb  ague."  In  children  a  convulsion 
may  take  its  place. 


MALARIA  245 

2.  The  Hot  Stage— Tms.  gradually  develops  after  the  chill.  As  the 
skin  becomes  warm,  the  sensation  of  cold  gives  place  to  that  of  intense 
heat.  The  face  and  hands  become  flushed  and  the  entire  body  becomes 
burning  .hot.  The  heart's  action  is  often  violent,  the  pulse  full  and 
bounding.  Severe  headache,  great  thirst,  and  restlessness  are  not  un- 
usual ;  there  may  be  delirium  of  short  duration.  The  course  of  the  fever 
is  characteristic.  After  attaining  its  maximum  within  one  or  two  hours, 
it  begins  to  decline  within  from  a  half-hour  to  three  hours,  and  reaches 
the  normal,  or  a  point  1°  to  2°  F.  (0.5° — 1.0°  C.)  below  normal,  within 
8  to  I  2  hours  from  the  beginning  of  the  attack. 

3.  The  Sweating  Stage. — Sweating  begins  with  the  decline  of  the  tem- 
perature. As  a  rule,  it  is  profuse.  With  it  the  headache  and  feeling  of 
discomfort  subside  and  the  patient  often  falls  into  a  refreshing  sleep. 

The  paroxysms  usually  occur  at  the  same  hour  each  day.  VVhen, 
however,  they  are  increasing  in  severity  they  frequently  come  on  from  a 
half-hour  to  an  hour  earlier,  and  when  they  are  decreasing  in  severity 
they  may  be  delayed  from  one  to  several  hours. 

Other  symptoms  frequently  appear,  especially  after  the  occurrence  of 
several  paroxysms.  There  is  a  recognizable  enlargement  of  the  spleen 
after  almost  every  paroxysm.  This  at  first  subsides  in  the  interval,  but 
it  soon  becomes  constant  and  progressive,  and  does  not  subside  for 
several  weeks  after  recovery.  The  organ  may  be  sensitive  to  pressure. 
The  enlargement  of  the  liver  is  seldom  recognizable  in  this  type  of  the 
disease.  The  urine  shows  the  febrile  changes,  concentration  with  increase 
of  color  and  solids,  rarely  albumin.  A  marked  diminution  of  the  quan- 
tity of  urea  has  been  noted  five  or  six  hours  before  the  chill.  Herpes 
appears  at  the  angles  of  the  mouth  or  on  the  alae  of  the  nose  in  about 
one-fourth  of  the  cases.  "  Masked  malarial  fever"  is  sometimes  encoun- 
tered, in  which  the  paroxysms  are  replaced  by  violent  attacks  of  neu- 
ralgia, affecting  the  supra-  or  infraorbital,  intercostal,  sciatic,  or  other 
nerves,  lasting  8  to  12  hours  and  recurring  at  regular  intervals. 

11.  Symptoms  of  the  Estivo-An-tumnal  (Remittent )  Fever. — This  form 
may  be  preceded  by  symptoms  of  much  the  same  character  as  those  of 
the  intermittent  type.  A  few  tertian  paroxysms  may  occur.  In  many 
cases,  however,  the  invasion  is  more  insidious,  the  chill  is  mild  or  it  may 
be  absent.  The  temperature  rises  more  gradually,  and  during  the  first 
few  days  it  may  not  attain  a  great  height.  One  paroxysm  is  said  to 
"anticipate"  another;  that  is,  a  second  paroxysm  comes  on  before  the 
temperature  of  the  first  has  fully  declined.  There  is,  therefore,  no  complete 
intermission.  After  a  few  days  the  temperature  becomes  continuous  in 
character  and  the  remissions  may  become  comparatively  slight.  Nausea 
and  vomiting  are  often  prominent  symptoms,  and  bronchitis  is  usually 
present.  There  is  frequently  also  diarrhea  with  adbominal  tenderness 
and  discomfort.  The  pulse  becomes  rapid,  often  120  to  130,  small  and 
feeble.  Headache,  restlessness,  and  insomnia  are  common,  and  there  may 
be  slight  delirium,  especially  at  night;  stupor  and  coma  may  follow. 
Profuse  sweating  occurs,  usually  at  night,  and  the  temperature  declines 
to  a  variable  degree;  but  it  rises  again  in  the  morning,  without  chill  or 
other  evidence  of  a  renewal  of  the  paroxysm.  The  temperature  often 
reaches  105°  or  106°  F.  (40.5° — 41.0°  C).  The  duration  of  the  disease 
is  indefinite.     Some  cases  yield  readily  to  treatment,  while  others  are  ex- 


2  46  PRACTICE  OF  MEDICINE 

ceedingly  refractory,  lasting  from  two  to  four  weeks  or  longer,  and  re- 
lapses are  common. 

A  grave,  pernicious  type  of  the  fever  may  develop,  and  the  general 
appearance,  particularly  of  the  face  and  tongue,  _and  the  temperature 
curve,  may  all  conform  to  the  features  of  typhoid  fever.  The  name 
typhomalarial  fever  was  formerly  applied  to  these  cases  by  many  clini- 
cians. The  more  prolonged  cases  are  frequently  accompanied  with  jaun- 
dice, which  varies  from  a  slight  tingeing  of  the  skin,  with  light  yellow 
conjunctivae,  to  the  deeper  saffron  shades  (bilious  remittent  fever).  A 
catarrhal  duodenitis,  with  the  usual  symptoms,  sometimes  develops  dur- 
ing the  course  of  the  fever  or  during  convalescence. 

III.  Symptoms  of  the  Pemidoiis  Form. — The  course  of  this  form  differs 
from  that  of  the  intermittent  or  remittent  chiefly  in  its  severity,  and 
more  particularly  in  the  occurrence  of  severe  gastrointestinal,  hemor- 
rhagic, or  cerebral  manifestations.  In  periodicity  it  may  conform  to 
either  type,  but  this  feature  is  often  lost.  It  is  not  a  common  form  of 
the  disease  in  America,  being  encountered  for  the  most  part  in  the 
warmer  climates,  notably  in  the  West  Indies  and  the  tropics.  Many 
cases  have  been  observed  among  the  soldiers  returning  from  the  Philip- 
pines.   Three  principal  types  are  recognized  : 

1.  The  Algid  Type  ( Coiigestive  Chills). — This  form  is  characterized  by 
profound  disturbances  on  the  part  of  the  gastrointestinal  tract,  often 
with  thrombosis  of  the  smaller  vessels  of  the  mucosa,  with  necrosis  and 
ulceration.  The  disease  may  begin  with  a  chill  or  chilly  sensations, 
usually  accompanied  with  nausea,  vomiting,  and  great  prostration. 
This  is  soon  followed,  in  most  cases,  by  a  profuse  diarrhea.  The  dis- 
charges are  copious  and  watery,  like  those  of  cholera;  or  they  may  be 
dysenteric,  containing  blood  and  mucus.  The  temperature  is  usually 
normal  or  subnormal;  fever  is  unusual.  The  pulse  is  accelerated  and 
feeble,  the  breathing  rapid  and  labored.  The  body  is  frequently  bathed 
in  a  cold,  clammy  perspiration.  A  fatal  collapse  may  supervene  within 
a  few  days,  or  jaundice  may  develop  and  the  case  may  thus  resemble 
one  of  yellow  fever. 

2.  Comatose  Type. — The  attack  may  be  ushered  in  with  a  chill,  fol- 
lowed for  a  few  days  by  fever,  but  ordinarily  the  chill  is  absent  and  the 
patient  passes  directly  into  a  state  of  stupor  or  delirium  that  merges 
into  a  profound  coma.  Hyperpyrexia  is  the  rule,  the  temperature  reach- 
ing io6°  or  107°  F.  (41.0° — 41.5°  C).  The  respiration  is  rapid,  feeble, 
and  superficial;  it  may  assume  a  Cheyne-Stokes  character.  The  condi- 
tion may  prove  fatal  within  the  first  48  hours,  or  a  partial  recovery 
may  be  followed  by  a  fatal  relapse.  It  is  in  this  form  of  the  disease 
that  the  cerebral  vessels  become  obstructed  by  the  parasites. 

3.  Hemorrhagic  Type. — The  malarial  infection  is  manifested  by  a  ten- 
dency to  hemorrhages,  particularly  from  the  kidneys  and  the  mucous 
membranes.  There  may  be  an  initial  chill  and  elevation  of  the  tempera- 
ture, but  these  are  often  absent.  In  one  class  of  cases  hemoglobin 
alone  appears  in  the  urine  (hemoglobinuria),  while  in  another  class 
blood-cells  are  also  found  (hematuria).  Casts  are  also  discovered  in 
some  cases.  The  gums  are  usually  swollen  and  bleed  spontaneously  or 
upon  slight  irritation.  There  may  be  also  bleeding  from  the  nose, 
lungs,  stomach,  and  intestines,  and  ecchymoses  appear  in  the  skin.    Jaun- 


2 so  PRACTICE  OF  MEDICINE 

has  been  most  fatal  in  New  England.  Epidemics  are  not  frequent  in  this  country.  The 
disease  becomes  less  prevalent  with  the  progress  of  sanitary  improvements.  In  the  West 
Indies,  and  more  particularly  in  the  Philippine  Islands,  it  constitutes  a  large  per  cent- 
age  of  the  total  illness. 

Definition. — An  infectious  disease,  endemic  in  the  tropical  zone,  spor- 
adic or  epidemic  in  the  temperate ;  characterized  pathologically  by  catar- 
rhal, croupous,  or  ulcerative  inflammation  of  the  large  bowel,  and  clini- 
cally by  frequent  mucous,  serous,  or  bloody  dejections,  accompanied  with 
tormina  and  tenesmus  and  more  or  less  severe  general  symptoms. 

Etiology. — The  direct  cause  of  the  disease  is  probably  a  micro- 
organism in  all  cases.  The  ameba  coli  and  the  bacillus  dysenteriae  are 
recognized  causes.  Their  relation  to  forms  of  the  disease  will  be  con- 
sidered under  separate  heads.  The  predisposing  causes  may  be  consid- 
ered together.  One  of  the  most  important  of  these  is  the  contamination 
of  drinking-water  with  the  dejecta  of  dysenteric  patients,  through  defec- 
tive drainage  or  otherwise.  That  there  are  other  modes  of  conveying 
the  infection  is  highly  probable.  That  the  disease  is  contagious  is  pos- 
sible, though  not  probable.  Disturbances  of  digestion,  particularly  as 
a  result  of  eating  improper  food,  unripe  fruit,  imperfectly  cooked  vege- 
tables; constipation,  and  starvation  are  important  factors.  Crowding 
and  imperfect  ventilation,  fatigue,  loss  of  sleep,  anxiety  and  chronic 
alcoholism,  favor  infection. 

Age  and  Sex. — No  age  is  exempt,  but  males  are  somewhat  more  fre- 
quently attacked  than  females,  probably  on  account  of  greater  ex- 
posure.    There  is  no  racial  immunity. 

Climate  and  Season. — The  disease  is  more  frequent  in  hot  seasons  in 
all  climates.  It  has  prevailed  most  extensively  in  the  United  States 
during  August  and  the  succeeding  fall  months.  Atmospheric  moisture 
appears  to  favor  its  spread  when  associated  with  either  extreme  heat 
or  cold.  Sudden  changes  of  temperature,  as  when  cool  nights  succeed 
to  hot  days,  also  favor  it. 

Forms  of  Dysentery. — The  marked  difference  in  the  severity  of  different 
cases,  and,  perhaps,  more  particularly  the  discovery  of  two  very  different 
micro-organisms  in  relation  to  the  disease,  have  led  to  a  separation  of 
the  cases  into  diff'erent  groups.  It  is  probable,  however,  that  more 
accurate  study  will  result  either  in  establishing  the  identity  of  the 
different  forms  or  in  giving  lis  a  better  classification.  Four  varities  of 
dysentery  are  now  recognized:  (i)  Acute  catarrhal,  or  sporadic;  (2) 
amebic;  (3)  diphtheritic,  or  that  due  to  the  bacillus  dysenteriae;  and 
(4)  chronic  dysentery,  which  may  follow  either  of  the  preceding  forms. 

I.  Acute  Catarrhal  Dysentery. 

Etiology. — This  form  is  probably  due  to  a  specific  micro-organism. 
It  not  infrequently  occurs  as  a  secondary  aff'ection  in  the  course  of  such 
diseases  as  tuberculosis,  syphilis,  chronic  nephritis;  or  follows  scurvy, 
cholera,  malaria,  and  other  affections.  The  investigations  of  Flexner 
and  Strong  indicate  that  all  these  cases  are  due  to  the  bacillus  dysen- 
teria;  described  by  Shiga.  Park  and  Carey  believe,  however,  that  a 
group  of  bacilli,  rather  than  an  individual  organism,  is  embraced  under 
this  term. 


DYSENTERY  249 

the  intermittent  type  it  is  not  necessary  to  give  the  remedy  at  regular 
intervals  between  the  paroxysms.  One  dose  of  from  10  to  20  grains 
(0.65 — 1.30)  five  hours  before  the  anticipated  chill  is  of  more  advantage 
than  several  times  as  much  given  at  another  time.  This  method  is 
largely  used  in  hospitals,  and  it  is  seldom  that  a  second  paroxism  is 
seen.  Some  physicians  prefer  to  give  a  similar  dose  immediate!}-  after 
the  paroxysm,  others  give  it  in  doses  of  5  grains  (0.32)  everj^  three 
hours.  It  should  be  given  in  capsules  or  wafers  or  in  solution.  In  chil- 
dren and  sometimes  on  account  of  irritability  of  the  stomach,  it  must 
be  given  by  the  rectum.  The  old  practice  of  beginning  the  treatment 
with  a  calomel  purge  is  often  beneficial,  as  it  frequently  removes  a  condi- 
tion which  interferes  with  the  absorption  of  the  quinin. 

The  treatment  should  be  continued  until  the  spleen  has  returned  to 
its  normal  size.  Arsenic  may  be  administered  (3  drops  of  Fowler's  solu- 
tion t.  i.  d.)  for  several  weeks  after  discontinuance  of  the  quinin. 

In  the  remittent  estivo-autumnal  type  of  the  disease  it  is  often  im- 
possible to  anticipate  the  paroxysms.  The  quinin  must  then  be  given  at 
regular  intervals  and  in  sufficiently  large  doses  to  produce  physiological 
effects  in  the  shortest  time  possible.  It  often  happens,  particularly  in  the 
pernicious  form,  that  the  remedy  is  not  retained  or,  if  retained,  it  fails  to 
produce  the  desired  effect.  It  is  then  better  to  administer  it  hypodermi- 
cally  in  the  form  of  the  hydrobromate,  hydrochlorid,  or  bisulphate,  in 
doses  of  15  to  30  grains  (i.o — 2.0)  once  or  twice  a  day.  The  adminis- 
tration of  a  calomel  purge  at  the  beginning  is  advisable  also  in  this 
form.  There  has  been  much  discussion  in  regard  to  the  action  of  quinin 
in  hematuria.  Some  writers,  especially  in  the  North,  claim  benefit  from 
it,  while  others,  in  warm  climates,  assert  that  it  is  generally  harmful. 

The  unpleasant  symptoms  of  cinchonism  may  be  lessened  by  the  ad- 
ministration of  20  to  30  grain  (1.5 — 2.0)  doses  of  potassium  bromid. 
It  is  often  necessary  to  give  opium  in  the  form  of  Dover's  powder,  codein, 
or  morphin  hypodermically,  for  the  restlessness.  Other  remedies  are 
required  in  some  cases  :  Stimulants  for  prostration ;  iron  and  arsenic, 
codliver  oil  and  malt,  for  the  anemia;  opium  and  bismuth  for  the  diar- 
rhea. Other  remedies  have  also  been  employed  to  combat  the  disease, 
notably  iodin,  ammonium  chlorid,  salicin,  and  eucalyptol.  Warburg's 
tincture  is  also  highly  esteemed  by  some  writers,  and  often  produces 
effects  not  easily  accounted  for.  Most  of  these  remedies  are  applicable, 
however,  only  to  the  interval  or  to  the  chronic  and  cachectic  conditions. 

Quite  recently  Gautier  has  found  a  powerful  specific  for  the  disease  in 
disodic  methylarsenate.  It  may  be  administered  by  the  mouth,  but  is 
more  active  when  given  hypodermically  in  the  dose  of  gr.  ^^  to  ^  (0.05 — 
o.io).  Recovery  has  been  observed  to  follow  one  or  two  injections  after 
quinin  had  failed  to  arrest  the  disease. 

DYSENTERY. 

THE  BLOODY  FLUX. 

Dysentery  is  one  of  the  oldest  of  known  diseases.  Although  it  is,  in  the  strict  sense 
of  the  term,  ubiquitous,  occurring  everywhere,  it  is  most  common  and  most  virulent  in 
the  tropics,  where  it  frequently  becomes  epidemic  and  more  fatal  than  the  cholera.  In 
army  life  it  is  most  dreadful.     It  is  encountered  in  all  parts  of  the  United  States,  but  it 


248  PRACTICE  OF  MEDICINE 

that  the  diagnosis  is  difficult,  even  without  examination  of  the  blood. 
This  form  so  frequently  corresponds  in  its  symptomatology  to  typhoid 
fever,  pyemia,  or  pneumonia  that  its  recognition  may  be  difficult  until 
the  Plasmodium,  crescents,  flagella,  or  pigment  granules  have  been  dis- 
covered in  the  blood. 

Typhoid  fever  does  not  usually  begin  with  a  severe  chill,  the  rise  of 
temperature  is  gradual,  the  plasmodium  is  absent,  and  the  Widal  test  is 
usually  positive. 

Pyemia  is  characterized  by  chills,  fever,  and  sweating  at  less  regular 
intervals;  a  focus  of  suppuration  can  generally  be  found;  there  is  leuco- 
cytosis,  and  the  plasmodium  is  absent.  The  spleen  is  not  so  greatly  en- 
larged.    Septicemia,  if  chills  be  present,  conforms  in  character  to  pyemia. 

Acute  tuberculosis  presents  symptoms  resembling  pyemia  rather  than 
malaria.  Physical  examination  usually  reveals  a  pulmonary  lesion, 
and  the  bacillus  tuberculosis  may  be  found  in  the  sputum. 

AVo^r/jos/s.— Malaria  is  attended  with  a  high  mortality  only  in  the 
tropical  countries,  and  this  pertains  especially  to  the  pernicious  estivo- 
autumnal  type.  In  any  case  the  prognosis  depends  chiefly  upon  the 
number  of  previous  attacks,  the  severity  of  the  type,  and  the  promptness 
of  treatment.  Repeated  attacks  very  often  leave  permanent  enlargement 
of  the  spleen,  persistent  anemia,  disordered  digestion,  and  impairment  of 
one  or  more  functions,  especially  of  the  nervous  system.  Complete  re- 
covery seldom  occurs  in  the  tropics. 

Prophylaxis.— This  consists  in  :  (i)  The  destruction  of  the  parasite,  or 
of  its  intermediate  host,  the  mosquito;  (2)  the  prevention  of  inoculation ; 
and  (3)  fortification  of  the  system  against  the  development  of  the  para- 
sites after  they  have  gained  entrance.  Theoretically  the  plasmodium 
may  be  destroyed  by  the  drainage  of  swamps  and  stagnant  pools.  The 
extermination  of  the  mosquito  is  a  more  positive  means  of  preventing 
the  disease.  This  is  to  some  extent  accomplished  by  drainage.  Fish 
destroy  the  ova  and  larvae,  but,  unfortunately,  they  can  rarely  live  in  the 
marshes.  Petroleum  has  been  found  to  be  the  best  agent  for  destroying 
the  mosquito.  A  mere  film  of  it  upon  the  surface  of  the  water  quickly 
kills  the  larvae  and  nymphae.  One  barrelful  is  sufficient  to  cover  a 
surface  of  96,000  square  feet.  It  should  be  used  early  in  the  spring. 
Mosquitoes  should  be  excluded  from  dwellings  and  tents  by  the  use  of 
bars  and  screens.  They  may  be  to  some  extent  driven  away  by  the 
diffusion  of  such  odors  as  pennyroyal,  nutmeg,  or  camphor,  or  by  the 
application  of  volatile  oils  to  the  skin.  The  system  is  best  fortified 
against  the  parasite  by  the  administration  of  quinin,  gr.  iij  or  iv 
(0.20 — 0.25),  morning  and  evening,  or  three-drop  doses  of  Fowler's  so- 
lution of  arsenic  after  each  meal,  during  the  season  of  greatest  exposure. 

Treatment.— The  patient  should  go  to  bed  as  soon  as  a  chill  com- 
mences. There  is  no  means  of  arresting  it,  but  the  suffering  may  be 
moderated  by  hot  drinks  and  the  application  of  dry  heat  to  the  body. 
The  administration  of  aromatic  spirit  of  ammonia,  3  ss  (1.85)  or  chloro- 
form, Tf|,xv  (i.o),  in  hot  coffee  or  lemonade  affords  some  relief.  The 
body  should  be  sponged  with  cool  water  during  the  hot  stage,  and  dried 
with  a  warm  towel  during  the  sweating. 

Quinin  is  a  specific  for  the  disease.  It  must  be  given  in  doses  and 
at   intervals    appropriate    to  the  form  of  the  disease  to  be  treated.    In 


MALARIA  247 

dice  is  a  common  accompaniment.  In  the  United  States  this  form  of  the 
disease  is  confined  chiefly  to  the  Gulf  Coast.  It  is  more  common  in  the 
West  Indies  and  in  tropical  countries.  It  is  sometimes  seen  in  individuals 
who  have  suffered  from  severe  and  prolonged  attacks  of  malaria.  In 
such  persons  there  are  usually  periodic  attacks  in  which  the  urine  be- 
comes scant  and  discolored  by  hemoglobin.  The  fatal  "  black-water" 
fever  of  the  Gold  Coast,  in  Africa,  belongs  to  this  type.  The  predomi- 
nance of  special  symptoms  has  led  to  the  adoption  by  different  writers 
of  such  names  as  cardiac,  choleraic,  diaphoretic,  gangrenous,  gastric, 
pleuritic,  pneumonic  and  syncopal,  pernicious  malaria. 

IV.  Malarial  Cachexia  (Chronic  Malaria). — This  condition  develops 
after  frequently  repeated  or  very  prolonged  attacks  of  intermittent  or 
remittent  fever.  It  sometimes  appears  in  the  residents  of  malarious  dis- 
tricts who  have  not  suffered  from  distinct  paroxysms  (latent  malaria). 
The  condition  is  seldom  seen  in  the  Northern  States,  but  it  is  not  un- 
common in  Cuba,  and  it  is  exceedingly  prevalent  in  Hawaii,  where  it 
often  adds  an  element  of  much  gravity  to  other  diseases.  It  may  as- 
sume the  form  of  recurrent  paroxysms  separated  by  an  interval  of  two, 
three,  or  four  weeks,  and  lasting  for  months ;  or  there  may  be  ill-defined 
manifestations  of  various  kinds.  The  most  characteristic  symptoms  are 
profound  anemia  and  enlargement  and  firmness  of  the  spleen,  often 
almost  equal  to  that  of  leukemia.  Fever  is  not  always  a  feature  of  the 
condition,  but  it  is  more  usual  than  chills.  The  blood-count  shows  an 
extreme  anemia.  There  may  be  only  1,000,000  corpuscles  to  the  cubic 
millimeter.  Free  pigment  granules,  crescents,  and  flagella  are  often  found. 
The  skin  is  usually  of  a  dull,  dusky  yellow  or  "muddy"  color,  or  the 
jaundice  may  be  as  deep  as  saffron.  The  urine  frequently  shows  the  pres- 
ence of  bile  pigments.  The  tongue  is  pale,  broad,  flat,  and  flabby,  showing 
the  indentations  of  the  teeth  and  coated  with  a  white  fur.  The  breath  is 
foul,  and  the  digestion  is  weak.  Constipation,  sometimes  alternating  with 
diarrhea,  is  the  rule.  The  stools  are  light  in  color,  sometimes  chalky. 
Lassitude,  mental  depression,  and  muscular  weakness,  sometimes  accom- 
panied by  aching  pains,  are  common  symptoms.  The  circulation  is  weak, 
and  edema  of  the  ankles  often  appears  in  the  evenings,  especially  after 
long  standing.  Periods  of  fever  occur,  but  in  some  cases  the  tempera- 
ture is  for  the  most  part  slightly  below  normal.  Hemorrhages  from  the 
mucous  membranes  or  into  the  skin,  retina,  and  other  tissues  are  occa- 
sionally observed,  and  a  distinctly  scorbutic  condition  may  develop. 

The  malarial  cachexia  is  one  of  the  most  persistent  forms  of  malarial 
infection.  Change  of  climate  may  give  temporary  relief,  but  a  return 
to  a  malarious  district  is  promptly  followed  by  a  relapse.  This  fact  has 
been  well  exemplified  in  the  cases  of  soldiers  who  contracted  the  disease  in 
Cuba,  recovered  at  home,  and  relapsed  upon  reaching  the  Philippines. 

Complicaiions. — Complications  arise  in  about  10  per  cent  of  all  cases. 
They  are,  in  the  order  of  frequency  :  enteritis,  nephritis,  rheumatism, 
typhoid  fever,  lobar  pneumonia,  jaundice,  and  dysentery  (Anders).  A 
number  of  other  conditions  may  result  more  or  less  directly  from  the 
infection,  among  them  such  paralyses  as  hemiplegia  and  aphasia ;  spinal 
irritation ;  optic  neuritis  and  retinal  hemorrhages,  amblyopia  and  other 
disturbances  of  vision ;  pulmonary  congestion,  and  asthma. 

Diagnosis. — It  is  only  in  the  estivo-autumnal  type  of  malaria,  as  a  rule, 


DYSENTERY 


251 


Morbid  Anatomy.— The  lesions  are  most  frequently  found  in  the 
rectum  and  flexures  of  the  colon.  They  are  sometimes  limited  to  the 
rectum  (proctitis).  The  affected  mucous  membrane  is  hyperemic  and 
swollen  and  is  usually  covered,  in  areas  of  variable  extent,  with  mucus, 
pus,  and  blood.  The  epithelial  layer  is  absent,  and  the  exfoliation  may 
have  extended  to  the  glands.  Superficial  ulcers  are  found,  and  occasion- 
ally a  few  which  have  extended  through  the  submucosa.  Punctiform 
hemorrhages  may  be  discovered  in  the  mucous  membrane  and  sub- 
mucosa. The  solitary  follicles  are  swollen  and  sometimes  distended  with 
pus,  or  they  may  have  burst  and  given  place  to  ulceration. 

Symptoms. — The  disease  may  be  mild  or  severe.  The  milder  cases 
often  begin  with  the  symptoms  of  an  ordinary  diarrhea,  free  watery 
passages  with  scybala.  Tympanites  and  abdominal  pains  develop;  the 
passages  become  small  and  painful,  and  they  are  composed  chiefly  or 
entirely  of  blood-stained  mucus.  The  microscope  reveals  a  granular 
de'bris,  red  and  white  blood-cells,  and  degenerated  epithelial  cells  which 
are  sometimes  mistaken  for  amebae.  A  large  number  of  bacteria  are 
usually  found,  and  the  cercomonas  intestinalis  is  sometimes  seen.  Grip- 
ing pains  (tormina)  are  an  almost  constant  feature.  They  begin  usually 
at  the  umbilicus  and  extend  to  the  region  of  the  ascending  or  descend- 
ing colon,  causing  urgent  desire  for  evacuation.  This  is  attended  with 
intense  involuntary  straining  (tenesmus),  and  followed  by  burning 
pain  in  the  anus.  Vesical  tenesmus  is  often  added  to  the  patient's 
sufi'ering.  Prolapse  of  the  rectum  often  occurs,  especially  in  children. 
The  abdomen  becomes  flat  and  highly  sensitive  to  pressure,  particularly 
over  the  colon.  There  is  little  constitutional  reaction  and  little  or  no 
fever,  as  a  rule.  Improvement  begins  in  from  three  to  five  days,  and 
recovery  may  be  complete  in  a  week  or  10  days. 

Severe  cases  usually  last  from  two  to  three  weeks.  The  symptoms 
are  those  of  the  milder  form,  but  more  severe,  particularly  at  night. 
The  discharges  are  usually  from  20  to  40  in  24  hours;  they  sometimes 
reach  150  to  200  within  that  time.  The  dejections  consist  of  a  serous 
fluid  containing  flakes  or  masses  of  mucus  and  blood.  After  ulceration 
has  begun,  usually  about  the  fifth  or  sixth  day,  pus  appears  in  them. 
The  temperature  reaches  101°  to  103°  F.  (38.5°— 39.5°  C.)  or  higher. 
The  pulse  is  accelerated  and  often  becomes  feeble.  The  prostration  may 
he  extreme.  The  tongue  becomes  dry  and  the  thirst  imperative.  The 
patient  suffers  intensely  from  loss  of  sleep,  not  due  to  ordinary  insomnia, 
but  to  the  intense  sufi'ering.  When  this  is  not  relieved,  delirium  some- 
times develops.  When  recovery  occurs,  the  symptoms  gradually  subside, 
and  fecal  matter  again  appears  in  the  dejections.  Death  may  result 
from  the  physical  and  mental  exhaustion.  The  disease  sometimes  passes 
into  a  chronic  condition. 

2.  Acute  Amebic  Dysentery. 

Etiology. — This  form  of  the  disease  is  endemic  in  India,  Japan,  the 
Philippine  Islands,  and  other  tropical  regions;  hence  it  is  often  referred 
to  as  "tropical  dysentery."  But  it  is  by  no  means  pecuhar  to  the  tropics. 
The  other  forms  are  frequent  there,  and  sporadic  amebic  dysentery  is 
encountered  in  diff"erent  parts  of  the  United  States.     It  is  due  to  the 


252 


PRACTICE  OF  MEDICINE 


ameba  coli,  a  peculiar,  irregularly  shaped  body  from  one  and  a  half  to 
faur  times  as  large  as  a  red  blood-corpuscle,  having  a  pale  nucleus, 
vacuoles,  and  active  pseudopodia  (Fig.  20).  Other  micro-organisms, 
especially  the  pus-formers,  are  often  present  in  the  lesions.  The  eti- 
ological relation  of  the  ameba  to  the  disease  was  disputed  by  some 
writers  before  the  discovery  that  there  are  at  least  two  other  forms  of 
ameba. 

Morbid  Anatomy.— The  lesions  are  commonly  located  in  the  sigmoid 
flexure,  but  they  are  not  infrequently  found  also  in  the  rectum  and 
flexures  of  the  colon.  The  intestinal  wall  is  thickened  and  hyperemic, 
particularly  the  mucous  membrane,  which  is  also  covered  with  bloody 
mucus.  Nodular  prominences  appear  on  the  mucosa,  which  are  due  to 
edema  and  cellular  infiltrations  of  the  areas  in  the  submucosa.  Necrosis 
follows,  with  the  production  of  cavities,  which  often  communicate  with 
each  other  and  soon  reach  the  surface,  forming  large  ulcers.  Amebas 
and  other  organisms  are  found  clinging  to  the  surface  of  the  ulcer  and 
often  in  the  intertubular  spaces.  Follicular  ulcers  are  also  present,  but 
they  are  often  concealed  by  necrotic  (gangrenous)  masses.  In  some 
cases  abscesses  are  found  in  the  liver,  sometimes  also  in  the  lung,  usu- 
ally in  the  lower  lobe  of 
the  right,  and  these  may 
be  found  to  communi- 
cate through  the  dia- 
phragm with  an  abscess 
in  the  liver. 

Symptoms. — The  course 
of  the  disease  is  divided 
into  two  stages,  the 
catarrhal  and  the  ulcera- 


tive. 

Catar?-hal  Stage. — This 
Fig.  20.— Amebae  dysenteriae  from  an  abscess  of  the  liver,  often  begins  with  a  slight 

chill  and  moderate  fever, 
but  the  temperature  declines  in  a  few  days  unless  serious  intestinal, 
hepatic,  or  pulmonary  lesions  develop.  There  may  be  at  first  a  simple 
diarrhea,  but  the  dejections  soon  become  dysenteric.  In  some  cases 
they  are  of  this  character  from  the  beginning,  with  little  or  no  odor 
and  an  alkahne  reaction.  The  amebas  are  found  in  the  bloody  mucus. 
The  pain,  tenesmus,  and  other  symptoms  are  similar  to  those  of  the 
catarrhal  dysentery,  but  the  tenesmus  is  not  usually  so  severe.  The 
diarrheal  stage  may  be  absent,  or  may  be  so  mild  as  to  be  unheeded, 
and  the  ulcerative  stage  may  begin  abruptly. 

Ulcerative  6"/^:^^.— The  symptoms  are  profound,  often  resembling  chol- 
era in  severity.  The  evacuations  become  more  and  more  numerous; 
they  contain  much  mucus  and  blood,  and  soon  become  fetid.  When 
gangrenous  destruction  of  the  mucous  membrane  occurs,  the  temperature 
often  declines  to  normal  or  becomes  subnormal.  The  extremities  then 
become  cold.  Hemorrhages  and  perforations  of  the  bowel  occasionally 
occur.  The  patient  may  die  in  collapse  due  to  the  intensity  of  the  dis- 
ease; from  exhaustion,  or  from  the  formation  of  abscess  in  the  liver  or 
lung.     But  the  course  of  the  disease  is  very  indefinite.     Remissions  and 


DYSENTERY  253 

exacerbations  are  common  and  the  condition  often  becomes  chronic  and 
lasts  for  several  months.    The  convalescence  is  always  slow. 

3.  Diphtheritic  Dysentery. 

Etiology. — This  form  of  the  disease  is  endemic  in  the  Philippines  and 
other  tropical  regions;  it  occasionally  becomes  epidemic  there  and  in 
other  parts  of  the  world,  and  sporadic  cases  are  occasionally  observed 
in  this  country.  A  very  large  part  of  the  dysentery  in  our  civil  war 
was  of  this  character.  It  has  been  observed  also  in  a  secondary  rela- 
tion to  various  acute  and  chronic  diseases,  notably  pneumonia,  chronic 
endocarditis  and  chronic  nephritis.  It  is  caused  by  the  bacillus  dys- 
enteria;,  a  slender  rod,  which  is  usually  found  in  the  intestinal  con- 
tents and  in  the  mesenteric  glands.  Flexner  in  his  studies  of  Philippine 
dysentery,  found  two  bacilli,  one  present  in  all  cases,  the  other  only 
in  the  most  acute.  Characteristic  lesions  and  symptoms  are  produced 
in  animals  inoculated  with  the  bacillus  and  by  the  injection  of  a 
toxin  separated  from  the  cultures.  One  human  experiment  is  recorded. 
A  healthy  Indian  criminal  condemned  to  death  voluntarily  ingested  a 
bouillon  culture  in  warm  milk  and  developed  the  disease  with  typical 
symptoms.  The  bacilli,  but  no  amebas,  were  found  in  the  stools.  Re- 
covery occurred  and  the  lesions  were  not  seen. 

Morbid  Anatomy. — The  lesions  may  involve  the  entire  colon  and  the 
rectum,  or  they  may  be  more  limited.  In  about  a  third  of  the  cases 
they  extend  from  10  to  15  cm.  into  the  ileum,  a  condition  not  observed 
in  amebic  dysentery.  Peyer's  patches  and  the  solitary  follicles  may  be 
slightly  enlarged.  The  wall  of  the  colon  is  thick  and  edematous  to  an 
extent  corresponding  to  the  severity  and  duration  of  the  attack.  The 
surface  of  the  mucous  membrane  is  red  or  of  a  reddish  brown  color  and 
covered  with  a  more  or  less  tenacious  pseudomembrane  composed  of 
fibrin  or  mucin  filaments  inclosing  blood-corpuscles  and  epithelium. 
Nodular  prominences  are  formed  in  the  mucosa,  especially  in  the  lower 
part  of  the  colon,  as  in  other  forms  of  the  disease.  One  of  the  most 
striking  features  of  the  morbid  anatomy  is  the  enormous  thickness  of  the 
colon  walls.  In  many  'cases,  no  ulcers  are  found.  There  is  only  an 
irregular,  superficial  erosion  of  the  epithelial  surface,  sometimes  involving 
the  entire  thickness  of  the  mucosa.  Under  the  microscope  the  section 
often  has  the  appearance  of  having  been  trimmed  with  a  pair  of  scissors. 
The  capillaries  are  enlcirged  and  hemorrhagic  areas  are  often  found.  The 
mesenteric  vessels  are  often  distended. 

Symptoms. — In  the  primary  form  of  the  disease  the  incubation  does 
not  exceed  48  hours.  The  onset  is  sudden,  often  with  chill  and  fever 
reaching  102°  to  104°  F.  (39° — 40°  C);  rapid  pulse,  from  120  to  150, 
as  the  disease  progresses.  The  stools,  as  in  the  other  forms  of  the  dis- 
ease, are  small  and  consist  of  mucus  and  blood,  becoming  more  frequent, 
the  pain  and  tenesmus  also  increasing.  The  tongue  usually  has  a 
whitish  fur.  The  thirst  is  excessive.  The  abdomen  is  not,  as  a  rule,  dis- 
tended, but  it  is  extremely  sensitive  to  pressure,  especially  along  the 
colon.  The  urine  is  gradually  reduced  in  quantity  and  often  becomes 
albuminous.  The  liver  and  spleen  retain  their  normal  size  in  most  cases. 
In   fatal  cases  the  dejections  often  become  less  frequent  and  the  patient 


254  PRACTICE  OF  MEDICINE 

may  sink  into  a  state  of  profound  collapse.  But  the  course  of  the  disease 
is  exceedingly  variable.  Severe  cases  rarely  recover;  death  usually  oc- 
curs from  the  fourth  to  the  tenth  day.  Convalescence  is  slow  and  relapses 
are  common.  They  are  often  precipitated  by  errors  in  diet  or  exercise. 
The  secondary  or  terminal  form  of  the  disease  may  for  a  time  be 
obscured  by  the  manifestations  of  the  affection  which  it  complicates,  or 
by  the  irregularity  of  its  symptoms.  Not  infrequently  there  are  several 
large  watery  dejections  daily  without  mucus  or  blood,  or  the  mucus 
and  blood  may  be  so  small  in  quantity  as  to  be  overlooked.  The  bacil- 
lus has  been  discovered  in  cases  occurring  in  the  course  of  chronic 
nephritis,  by  Flexner  and  Strong. 

Chronic  Dysentery. 

Either  of  the  acute  forms  may  pass  into  the  chronic.  The  disease, 
especially  the  amebic  form,  frequently  pursues  a  subacute  course. 

Morbid  Anaiomy. — Any  or  all  of  the  lesions  may  be  found  as  they  have 
been  described  under  the  several  acute  forms.  The  ulcers  are  usually 
numerous,  some  of  them  in  a  state  indicating  reparative  changes,  others 
showing  little  vitality.  As  a  result  of  the  continued  hemorrhages  and 
the  disintegration  of  blood,  the  ulcers  are  generally  pigmented.  The 
submucosa  and  muscular  coats  of  the  bowel  are  much  thickened.  Here 
and  there  among  the  ulcers  small  follicular  cysts  are  often  observed. 
In  some  cases  an  apparently  excessive  reparative  process  has  led  to  the 
development  of  much  new  connective  tissue,  the  contraction  of  which 
has  given  the  mucous  membrane  an  irregular,  uneven  surface,  showing 
in  some  places  deep  depressions,  in  others  polypoid  prominences.  The 
lumen  of  the  bowel  is  often  much  narrowed;  complete  strictures  are  not 
common.     In  exceptional  cases,  no  ulcers  are  found. 

Symptoms. — The  course  of  the  disease  is  not  at  all  uniform.  Many 
of  the  symptoms  of  the  acute  forms  of  the  disease  are  absent  or  they 
are  present  in  a  modified  form.  Pain  and  tenesmus  are  seldom  promi- 
nent features.  Many  cases  bear  a  close  resemblance  to  the  lienteric  type 
of  chronic  diarrhea,  the  passage  of  undigested  food  being  a  prominent 
symptom.  True  dysenteric  manifestations  are  "Seen  for  the  most  part 
only  during  exacerbations.  At  such  times  from  three  to  twelve  large, 
liquid  dejections  occur  during  the  course  of  24  hours.  They  are  often 
frothy,  especially  if  the  patient's  diet  has  been  largely  of  a  starchy 
nature.  The  character  of  the  symptoms  in  any  case  depends  largely 
upon  the  nature  of  the  food.  A  mixed  diet,  as  a  rule,  produces  large 
watery  stools.  Mucus  is  usually  present  in  variable  quantity.  In  the 
severe  cases,  particularly  those  of  the  amebic  form,  pus  and  blood  are 
often  discharged.  As  a  rule,  however,  neither  blood  nor  shreds  of 
necrotic  tissue  are  found  in  the  dejections.  In  another  class  of  cases 
the  stools  are  semifluid,  pultaceous^  and  of  a  yellow  or  brownish  color 
due  to  the  presence  of  bile.  Scybala  are  seldom  seen,  except  in  cases  in 
which  the  dysentery  alternates  with  constipation.  These  cases  occur  for 
the  most  part  when  the  disease  is  confined  to  the  lower  part  of  the  bowel. 
Flatulence  is  often  an  aggravating  symptom.  The  tongue  is  usually 
red  and  glazed,  seldom  coated.  In  protracted  cases  it  becomes  dry  and 
fissured.  Slight  tenderness  may  be  elicited  along  the  course  of  the  ileum. 
Emaciation  and  anemia  become  extreme  in  the  most  chronic  cases. 


DYSENTERY 


255 


Complications  and  Seque/ce.— The  complications  and  sequelae  of  acute 
and  chronic  dysentery  are  probably  more  numerous  than  those  of 
any  other  disease.  The  loss  of  blood  and  impairment  of  digestion 
rapidly  lead  to  malnutrition  and  anemia.  Other  conditions  result  in 
part  from  these,  in  part  from  toxic  or  septic  infection,  possibly  from  the 
direct  action  of  the  bacteria.  The  following  complications  have  been 
noted :  Catarrh  of  the  stomach  and  small  intestine,  perforation  of  the 
bowel  and  peritonitis,  prolapse  of  the  rectum,  hemorrhoids,  perineal 
abscess  and  fistula,  acute  bronchitis,  pleurisy,  pneumonia,  abscess  and 
gangrene  of  the  lung,  abscess  of  the  spleen,  endocarditis,  pericarditis, 
pyelophlebitis,  parotitis,  convulsions,  meningitis,  cerebral  embolism  with 
hemiplegia  and  aphasia,  thrombosis  of  the  cerebral  sinuses,  mono- 
plegias and  paraplegia  due  to  neuritis;  albuminuria,  chronic  nephritis, 
anuria,  edema,  ascites,  anasarca,  erysipelas,  and  various  forms  of  ar- 
thritis. The  disease  is  sometimes  associated  with  tuberculosis,  scurvy 
typhoid  fever,  typhus,  malaria,  or  other  diseases. 

Diagnosis. — \¥hen  the  dysentery  begins  with  frequent  small  dejections 
consisting  largely  of  mucus  and  blood,  accompanied  with  tormina  and 
tenesmus,  as  is  usually  the  case  in  the  acute  catarrhal  form,  the  diagnosis 
is  not  difficult.  The  diphtheritic  form  often  resembles  typhoid  fever  so 
closely  as  to  render  a  distinction  difficult.  It  is  seldom,  however,  that 
the  initial  symptoms  of  the  latter  disease  are  so  severe.  Blood  does 
not  appear  in  the  stools  so  early,  if  at  all,  and  it  is  usually  in  the  form 
of  a  profuse  hemorrhage.  The  presence  of  the  rose  spots,  and  the  serum 
test,  complete  the  diagnosis.  In  the  amebic  form  the  discovery  of  the 
parasites  in  the  stools  establishes  the  character  of  the  disease.  They 
should  be  searched  for  in  all  cases  of  persistent  atypical  diarrhea.  Leu- 
cocytosis  is  not  usually  present  unless  complications  have  developed. 

Prognosis. — The  disease  is  extremely  fatal  unless  the  treatment  be 
prompt  and  thorough.  Not  a  little  depends  upon  the  character  of  the 
disease  in  the  given  case,  the  constitution  of  the  patient,  and  his  hygienic 
surroundings.  The  mortality  at  different  times  and  in  different  places 
has  varied  from  less  than  10  to  more  than  90  per  cent.  In  the  tropics 
this  range  is  still  observed  in  some  instances.  In  Manila  recently  it 
was  only  9.5  per  cent. 

Prophylaxis. — This  is  practically  the  same  as  that  of  typhoid  fever. 
Thorough  sanitation  is  the  most  efficient  means  of  exterminating  the 
disease.  During  epidemics  raw  food  should  not  be  eaten  and  the  drink- 
ing-water should  be  thoroughly  boiled.  The  disinfection  of  dejecta 
should  be  rigidly  practiced. 

Treatment. — Each  form  of  the  disease  has  its  appropriate  treatment. 
The  acute  catarrhal  form  is  often  promptly  relieved  by  the  administra- 
tion of  a  purge.  The  effervescent  magnesium  citrate,  Rochelle  salts,  a 
half-ounce  in  a  glassful  of  water  every  hour,  an  ounce  of  castor  oil 
to  which  may  be  added  15  drops  of  deodorized  tincture  of  opium,  to 
relieve  the  griping;  either  remedy  may  be  employed.  The  purge  need 
not  be  repeated  unless  the  presence  of  scybala  or  continued  abdominal 
distress  and  desire  for  evacuation  indicate  that  the  bowel  has  not  been 
thoroughly  freed  of  its  irritating  contents.  After  thorough  evacuation, 
an  opiate  should  be  administered,  as  the  deodorized  or  camphorated 
tincture  of  opium,  Dover's  powder,  or  the  lead  and  opium  pill.  If  tenes- 
mus continues,  laudanum,  3  ss  (1.85),  in  starch-water,  or  a  suppository 


2  56  PRACTICE  OF  MEDICINE 

containing  cocain,  gr.  %  (0.016),  or  morphin,  gr.  ]/i  (0.032),  may  be  in- 
serted into  the  rectum.    Morphin  hypodermically  is  sometimes  required. 

Ipecacuanha  is  one  of  the  oldest  and  often  the  most  valuable  remedy, 
particularly  in  the  amebic  form  of  the  disease.  Its  action  is  almost 
specific  when  it  is  employed  at  the  very  beginning  of  the  attack.  The 
patient  should  abstain  from  all  food  for  at  least  three  hours  before  the 
remedy  is  administered,  then  take  20  drops  (TT|,xij — 0.75)  of  the  deodor- 
ized tincture  of  opium.  A  half-hour  later,  when  the  effect  of  the  opium 
is  becoming  apparent,  gr.  xx  to  xxx  (1.30 — 2.0)  of  the  powdered  ipe- 
cacuanha are  given,  preferably  in  pills  or  capsules,  with  as  little  water 
as  possible.  Keratin  capsules,  which  do  not  dissolve  in  the  stomach, 
may  be  used.  The  patient  must  lie  quietly  on  his  back,  not  even 
speaking,  in  order  to  prevent  vomiting.  The  saliva  must  not  be  swal- 
lowed, but  should  be  removed  on  a  cloth  with  the  assistance  of  the 
nurse.  If  vomiting  occur,  the  dose  should  be  repeated  in  an  hour  or 
two,  after  nausea  has  ceased,  otherwise  not  until  the  following  day. 

Bismuth  in  large  doses,  3  ss  to  3  j  (2.0 — 4.0)  every  two  or  three  hours, 
has  been  found  beneficial,  especially  in  chronic  cases.  Astringents  are 
usually  harmful. 

Irrigation  Treatment. — This  has  proved  one  of  the  most  effective 
methods  of  treatment.  The  chief  difficulty  in  its  way  is  the  great  ir- 
ritability of  the  bowel,  especially  in  acute  cases,  which  prevents  the 
retention  of  the  injected  fluid.  This  may  be  in  a  measure  overcome  by 
the  preliminary  introduction  into  the  rectum  of  a  cocain  suppository 
or  a  few  drops  of  a  4  per  cent  cocain  solution.  A  hypodermic  dose 
{yk  gr. ;  0.008)  of  morphin  may  be  given  unless  a  poisonous  antiseptic 
solution  is  to  be  employed.  The  irrigation  is  made  through  the  long 
rectal  tube,  using  from  2  to  6  pints  (i  to  3  liters)  of  the  solution  at 
a  temperature  of  100°  F.  (37.5°  C).  Pure  water  or  a  saline  solution 
may  be  used  first  to  cleanse  the  bowel,  then  an  antiseptic  or  astringent 
solution.  The  solutions  generally  employed  are :  Mercuric  chlorid 
(i  :5ooo),  quinin  (i  :25oo),  carbolic  acid,  tannic  acid,  zinc  sulphocar- 
bolate,  salicylic  or  boric  acid  (i  12000  or  stronger).  Care  must  be 
exercised  to  thoroughly  withdraw  the  solution  from  the  bowel,  especially 
if  poisonous.  Silver-nitrate  solution  is  one  of  the  most  reliable  remedies,, 
particularly  in  chronic  cases.  It  should  be  used  in  large  quantity, 
2  to  3  pints,  containing  gr.  xx  to  xxx  (1.3 — 2.0)  to  the  pint.  Irriga- 
tion should  be  practiced  once  or  twice  a  day. 

The  diet  should  be  largely  fluid  in  character,  consisting  of  milk,  meat 
broths,  beef-juice,  junket,  albumin  water,  milk-toast,  and  thoroughly 
boiled  rice.  During  convalescence  solid  food  must  not  be  allowed  too 
soon,  and  the  patient  should  not  be  permitted  to  leave  his  bed  or  in 
any  way  to  exert  himself  until  all  indication  of  intestinal  ulceration 
has  disappeared. 

SMALLPOX. 

VARIOLA. 

Previous  to  the  introduction  of  inoculation  b}'  Lad\'  Mary  Wortiey  Montagu  and 
vaccination  by  Edward  Jenner,  smallpox  was  one  of  the  worst  scourges  of  humanity. 
It  has  prevailed  from  the  earliest  antiquitj'  in  India  and  China,  and  to  such  an  e.\tent 
in  other  countries  that  its  origin  cannot  be  determined.      It    was   brought   to   the  West 


SMALLPOX 


257 


Indies  in  1507,  to  Mexico  in  1520,  and  to  the  United  States  in  1649.  From  its  orig- 
inal foothold  in  Boston,  it  spread  gradually  westward  until  it  reached  the  Pacific  coast 
about  one  hundred  years  later.  The  name  smallpox  was  given  to  the  disease  to  dis- 
tinguish it  from  syphilis,  the  "great  pox." 

Definition. — An  acute  infectious  disease  characterized  by  a  stidden 
onset  with  violent  pains  in  the  head  and  back,  rapid  rise  of  temperature, 
followed  by  a  remission,  and  an  eruption  which  passes  through  the 
stages  of  papule,  vesicle,  pustule,  and  crust,  sometimes  complicated  by 
cutaneous  and  visceral  hemorrhages.  The  mucous  membranes  may  also 
be  affected. 

Etiology.  — Smallpox  is  one  of  the  most  virulently  contagious  dis- 
eases. Susceptibility  to  it  is  all  but  universal.  The  negro  and  other 
dark  races  and  the  aborigines  of  all  countries  are  especially  predisposed 
to  it.  All  persons  unprotected  by  vaccination  are  almost  certain  to  be 
attacked  after  even  brief  exposure.  Natural  immunity  seems  to  be 
possessed  by  a  few  individuals,  for  there  have  been  instances  in  which 
persons  resisted  both  smallpox  and  vaccination.  The  immunity  con- 
ferred by  an  attack  is  not  alv/ays  permanent,  but  there  are  few  well 
attested  instances  of  a  second  or  third  attack. 

Age  a7id  Sex. — The  disease  spares  no  period  of  life,  but  it  is  relatively 
more  fatal  in  young  children.  Infants  have  been  born  with  the  eruption 
or  with  the  scars.  The  fetus  is  sometimes  attacked  in  utero,  when  the 
mother  is  suffering  from  the  disease;  but  it  may  escape  and  can  then  be 
saved  by  vaccination  immediately  after  its  birth.  Nurslings  are  believed 
to  be  less  susceptible  than  infants  of  a  year  or  more.  The  disease  is 
sometimes  contracted  in  extreme  old  age.  Sex  bears  no  relation  to 
susceptibility. 

The  Contagium. — The  ultimate  source  of  infection  in  all  cases  is  an 
individual  suffering  from  the  disease.  The  contagium  exists  in  the  cutane- 
ous lesions  and  doubtless  in  the  blood  and  secretions,  probably  also  in  the 
excretions,  of  the  patient.  It  is  given  off  in  the  exhalations  from  the  lungs 
and  skin,  but  it  is  nowhere  more  virulent,  perhaps,  than  in  the  crusts, 
which  are  believed  to  be  a  frequent  source  of  infection.  The  communica- 
tion of  the  disease  may  be  direct  or  indirect.  The  smallpox  patient  is 
always  a  source  of  infection  from  the  first  appearance  of  the  eruption  to 
the  completion  of  desquamation.  It  is  doubtful  whether  he  gives  off 
the  infection  before  the  appearance  of  papules,  but  in  one  instance  the 
disease  was  communicated  by  grafts  of  skin  taken  from  an  individual 
who  developed  the  disease  a  few  hours  later  (Thompson).  The  most 
contagious  periods  are  the  stages  of  suppuration  and  desiccation.  The 
disease  m.ay  be  transmitted  by  the  clothing,  bed-linen,  or  furniture;  by 
anything  that  comes  into  contact  with  the  patient.  The  contagium  is 
retained  by  such  fomites  for  years  if  protected  from  the  air,  and  may 
be  carried  to  a  great  distance.  It  has  thus  been  transported  across 
the  Atlantic  in  baled  rags.  It  clings  tenaciously  to  a  locality  and  is 
retained  for  some  time  in  the  body  after  death.  It  is  doubtless  carried 
to  a  considerable  distance  in  air  currents.  Observations  made  at  the 
Bradford,  England,  fever  hospital  indicate  that  it  may  be  thus  trans- 
mitted for  a  mile. 

Bacteriology. — The  protozoon  organism  recently  isolated  by  Council- 
man, McGrath,  and  Brinckerhoff  will  doubtless  prove  to  be  the  specific 

17 


258  PRACTICE  OF  MEDICINE 

cause  of  the  disease.  It  is  about  i2,a  in  diameter,  has  two  cycles  of 
development,  and  produces  spores  i,a  in  diameter.  The  sexes  appear 
to  be  distinct,  one  of  them  developing  only  in  the  cytoplasm  (proto- 
plasm) of  a  tissue  cell,  the  other  in  the  nucleus.  Numerous  micrococci, 
probably  pyogenic  in  character,  have  been  found  in  the  pustules. 

The  avenue  by  which  the  infection  enters  the  system  is  not  known, 
but  it  is  probably  the  respiratory  passages  in  most  instances.  The 
type  of  infection  is  not  always  transmitted,  for  the  mildest  case  of 
varioloid  may  give  rise  to  the  most  \arulent  form  of  smallpox  in  another 
person. 

Morbid  Anatomy. — T7ie  Eruption. — The  eruption  passes  through  four 
stages — the  papule,  vesicle,  pustule,  and  crust.  The  papule  corresponds 
to  an  area  of  hyperemia  in  the  rete  mucosum,  which  later  gives  place 
to  a  coagulation  necrosis  at  the  beginning  of  vesiculation.  The  filling 
of  the  vesicle  with  clear  serum  is  due  to  the  infiltration  of  the  intercel- 
lular spaces  with  lymph  containing  leucocytes  and  fibrin  filaments.  The 
interior  of  the  vesicle  has  a  reticulated  framework.  hj\  accumulation 
of  pus-cells  converts  the  vesicle  into  a  pustule.  The  depression  in  the 
center  of  the  pustule  corresponds  to  the  original  area  of  coagulation 
necrosis.  In  the  hemorrhagic  form  of  the  eruption,  blood-corpuscles 
are  found  in  the  vesicles  and  in  the  deeper  layers  of  the  epidermis 
around  them.  The  vesicle  often  surrounds  a  hair  follicle.  The  depth 
to  which  the  suppuration  extends  into  the  derma  determines  the  ex- 
tent of  subsequent  pitting.  The  entire  process  is  due  to  the  presence  of 
bacteria.  The  eruption  is  found  after  death,  not  only  in  the  skin  and 
visible  mucous  membranes,  as  those  of  the  mouth,  tongue,  cheeks,  palate, 
pharynx,  and  larynx,  but  to  a  variable  distance  down  the  esophagus, 
trachea,  and  bronchi,  sometimes  in  the  rectum.  Peyer's  patches  are  not 
infrequently  enlarged.  Owing  to  heat  and  moisture,  the  mucous  mem- 
brane eruption  is  soon  converted  into  ulcers.  Edema  and  membranous 
growth  are  often  associated  with  the  ulceration  in  the  larynx.  The 
laryngeal  cartilages  may  be  involved  by  a  deep  extension  of  the  ulcera- 
tion. 

The  blood-corpuscles  form  irregular  clumps  instead  of  rouleaux  under 
the  cover  slip.  Leucocytosis  is  generally  pronounced  at  the  height  of 
pustulation,  but  rapidly  declines  with  desiccation.  The  heart  sometimes 
shows  parenchymatous  or  fatty  change.  Endocarditis  and  pericarditis 
are  frequent. 

The  changes  in  the  liver  are  those  accompanying  febrile  diseases,  fatty 
degeneration,  hyperemia,  and  migration  of  leucocytes. 

The  spleen  is  enlarged  and  firm  in  the  hemorrhagic  form  of  the  disease. 
The  kidneys  may  show  cloudy  swelling  or  coagulation  necrosis,  and 
nephritis  sometimes  develops  during  convalescence.  Orchitis  is  some- 
times found.  In  the  hemorrhagic  form,  extravasations  of  blood  are 
found  in  the  parenchyma  of  various  organs,  in  the  connective  tissues, 
and  on  the  surfaces  of  the  serous  and  mucous  membranes,  in  the  mus- 
cles, bone  marrow,  and  elsewhere. 

Symptoms. — Three  forms  of  the  disease  are  recognized:  i.  Simple 
smallpox,  variola  vera;  2,  malignant  smallpox,  variola  maligna;  3, 
varioloid,  smallpox  modified  by  vaccination.  They  are  all,  however, 
different  forms  of  the  same  disease,  differing  chiefly  in  severity. 


SMALLPOX  259 

Variola  Vera. — Incubation. — The  average  duration  of  incubation  is 
12  days;  it  may  be  as  short  as  8  days  or  as  long  as  15,  rarely  longer. 
After  inoculation  the  disease  may  appear  in  48  hours.  There  are  usually 
no  prodromal  symptoms. 

Initial  eruptions  occur  during  the  stage  of  invasion  in  from  10  to 
16  per  cent  of  cases  and  are  often  of  great  diagnostic  value.  Two 
forms  of  eruption  are  thus  seen  :  («)  An  erythematous  rash,  which  may 
be  diffuse,  resembling  scarlatina  or  erysipelas;  and  (<^)  a  macular 
eruption  resembling  measles  or  urticaria.  They  are  usually  limited  to 
the  lower  abdominal  region,  inner  surface  of  the  thighs,  sides  of  the 
thorax  and  axillee,  or  inner  sides  of  the  arms,  but  occasionally  appear 
on  the  extensor  surfaces,  especially  near  the  elbows  and  knees.  The 
purely  erythematous  rash  is  of  prognostic  importance  also,  since  it  is 
almost  invariably  followed  by  a  mild  type  of  the  disease.  A  petechial 
eruption  appearing  at  this  early  period  is  generally  of  grave  import, 
being  followed,  as  a  rule,  by  the  malignant  form. 

Invasion.— Tht  onset  of  the  disease  is  generally  announced  by  a  chill 
or  a  succession  of  chills,  with  violent  frontal  headache,  intense  pain 
in  the  lumbar  region  and  extremities,  and  persistent  vomiting.  In  chil- 
dren the  chill  is  generally  replaced  by  one  or  more  convulsions.  Loss 
of  appetite  and  thirst  are  constant  accompaniments  of  the  disease. 
Vertigo  and  syncope  are  frequently  present;  the  tongue  is  furred,  the 
breath  is  fetid,  the  throat  sore,  and  the  bowels  are  usually  constipated. 
The  temperature  rapidly  rises,  reaching  103°  or  104°  F.  (39.5°— 40.0° 
C.)  on  the  evening  of  the  first  day,  and  remaining  high,  often  104°  or 
105°  F.  (40.0°— 40.5°  C),  until  the  eruption  appears.  The  pulse  is 
rapid,  100  to  130,  but  full;  seldom  dicrotic.  The  respiration  is  rapid 
and  labored,  often  out  of  normal  ratio  to  the  pulse.  The  face  is  flushed, 
the  eyes  are  bright  and  clear,  and  the  conjunctivae  are  congested.  The 
patient  is  generally  restless  and  anxious,  and  often  becomes  delirious 
within  the  first  few  days.  Profuse  sweating  occurs  in  many  cases.  The 
stage  of  invasion  lasts  three,  sometimes  four  days,  but  its  intensity  is 
not  an  indication  of  the  severity  of  the  subsequent  course  of  the  disease, 
for  the  initial  symptoms  of  varioloid  are  often  severe,  especially  in 
women  and  children. 

Stage  of  Eruption. — Four  types  of  eruption  may  be  encountered,  i. 
The  discrete;  2,  the  confluent;  3,  the  hemorrhagic;  and  4,  the  ver- 
rucose. 

I.  Discrete  Type.— The  eruption  makes  its  appearance  late  on  the 
third  or  on  the  fourth  day.  It  comes  out  first  upon  the  forehead,  at  the 
margin  of  the  scalp,  and  on  the  wrists.  Occasionally  it  appears  also  on 
the  hands,  sides  of  the  neck,  and  upper  lipi  It  appears  first  in  the  form 
of  little,  round,  slightly  elevated,  pale  red  blotches,  which  feel  to  the 
touch  like  bird-shot  in  the  skin,  often  before  they  can  be  distinctly  seen. 
They  can  sometimes  be  seen  in  the  mouth  ten  or  twelve  hours  sooner 
than  upon  the  forehead.  In  a  few  hours  these  original  blotches  become 
darker  in  color  and  distinctly  papular.  By  the  end  of  24  hours  they 
may  be  found  on  all  parts  of  the  body.  They  are  usually  less  numerous 
upon  the  trunk  than  upon  the  extremities;  the  hypogastrium  some- 
times escapes,  and  the  inner  sides  of  the  thighs  seldom  show  a  mature 
eruption. 


26o  PRACTICE  OF  MEDICINE 

On  the  fifth  or  sixth  day  of  the  disease,  as  a  rule,  the  papules  become 
converted  into  vesicles  containing  clear  serum.  These  appear  full  and 
have  an  almost  glistening  appearance  in  a  good  light.  WTien  punctured, 
they  do  not  collapse.  Within  a  day  or  two  they  become  umbilicated, 
a  small  indentation  appearing  in  the  center  of  each,  and  the  fluid  be- 
comes gradually  less  translucent,  rendering  the  pock  opalescent  and 
finally  opaque.  By  the  ninth  or  tenth  day  of  the  disease  the  vesicles 
are  thus  changed  into  pustules.  The  umbilication  is  then  lost,  and  the 
pock  assumes  a  full,  globular  form  about  the  size  of  a  split  pea  or 
larger.  Surrounding  each  pustule  is  a  zone  of  hyperemia,  the  "  halo" ; 
and  the  skin  between  the  pocks  is  reddened,  painful,  and  exquisitely  sen- 
sitive, particularly  on  the  face,  hands,  and  feet.  The  transformation  of 
papule  into  vesicle,  and  vesicle  into  pustule,  begins  on  the  face  and  follows 
the  same  order  of  progression  as  the  original  eruption. 

With  the  appearance  of  the  eruption  the  temperature  falls  nearly  or 
quite  to  the  normal ;  the  pain  and  other  symptoms  subside.  When  the 
pustules  mature,  the  temperature  again  rises  nearly  or  quite  as  high  as 
in  the  stage  of  invasion,  and  the  other  symptoms  return,  often  with 
even  greater  severity,  but,  as  a  rule,  the  temperature  begins  to  decline 
again  in  from  24  to  48  hours. 

The  swelling  of  the  face  is  so  great  at  this  time  that  the  eyes  are 
closed.  The  maturing  of  the  pustules  requires  about  three  days.  In  some 
cases  by  about  the  eleventh  day  the  pustules  begin  to  rupture,  either 
spontaneously  or  by  accident,  and  sometimes  the  pus  seems  to  ooze 
from  them  without  actual  rupture.  This  gives  the  patient  a  most  loath- 
some appearance  and  a  peculiar,  fetid  odor.  After  this,  desiccation 
rapidly  progresses.  The  crusts  are  usually  formed  by  the  fourteenth  or 
fifteenth  day  of  the  disease,  by  which  time  the  temperature  has  usually 
fallen  and  convalescence  is  fully  established.  Desquamation  begins  about 
a  week  later,  the  twent3^-first  to  the  twenty-fifth  day,  first  on  the  face, 
a,nd  follows  the  order  of  the  eruption.  In  severe  cases  the  fever  some- 
times continues  through  the  third  and  fourth  weeks. 

The  eruption  on  the  mucous  membranes  soon  becomes  converted 
into  more  or  less  confluent  ulcers,  as  stated  under  Morbid  Anatomy. 
The  lesions  are  seen  especially  in  the  mouth,  tongue,  soft  palate,  cheeks, 
the  conjunctivae,  in  the  nose,  pharynx,  rectum,  and  vulva,  and  are  usu- 
ally accompanied  with  intense  inflammation  of  the  surrounding  areas, 
seriously  interfering  with  the  function,  and  sometimes  leaving  such  per- 
manent damage  as  the  loss  of  sight. 

2.  Confluent  Type.— The  confluent  type  of  eruption  is  seen,  as  a  rule, 
only  in  the  most  severe  cases.  It  generally  appears  as  a  numerous 
collection  of  discrete  papules,  usually  on  the  second  day  of  the  disease, 
instead  of  the  third  or  fourth,  and  spreads  in  the  same  manner  as  does 
the  discrete  form.  The  confluence  is  due  to  the  coalescence  of  groups 
of  vesicles.  Large  blebs  are  thus  formed,  which  rupture  rapidly,  and 
the  entire  face  is  sometimes  covered  by  one  large,  firm  crust.  All  the 
symptoms  are  more  severe  and  more  protracted  than  in  the  discrete 
type,  and  there  is  little  or  no  remission  at  the  appearance  of  the  erup- 
tion. Sepsis  is  manifested  in  many  cases  by  the  occurrence  of  repeated 
chills  and  hyperpyrexia,  and  not  infrequently  this  is  the  cause  of  a  fatal 
issue.    The  nervous  manifestations  are  also  more  prominent.     The  de- 


SMALLPOX  261 

lirium  may  become  violent,  often  with  a  suicidal  tendency,  or  it  may 
pass  into  coma.  The  cervical  glands  become  markedly  swollen  in  most 
cases,  and  salivation  and  diarrhea  often  add  to  the  gravity  of  the  situa- 
tion. Desiccation  does  not  begin  until  the  third  or  fourth  week,  and  the 
crusts  separate  in  large  masses.  Osier  refers  to  entire  molds  of  the 
hands  and  feet. 

3.  Hemorrhagic  Type. — This  is  an  alteration  in  the  character  of  the 
eruption  which  is  due  to  the  escape  of  blood  into  the  vesicles  or  pus- 
tules. The  initial  hemorrhagic  eruption,  when  it  appears  in  the  malig- 
nant form  of  the  disease,  is  generally  accompanied  by  profuse  hemor- 
rhages from  almost  every  part  of  the  body  (see  Malignant  Smallpox). 
It  helps  to  make  up  the  symptomatology  of  the  disease  that  is  described 
as  purpura  variolosa;  hemorrhagic,  or  black,  smallpox. 

Another  form  of  hemorrhagic  eruption  is  seen  when  hemorrhage 
occurs  into  the  vesicles  or  pustules  at  any  time  during  the  course  of 
the  disease  (variola  hemorrhagica  pustulosa).  It  is  especially  likely  to 
occur  in  alcoholic  subjects,  or  others  in  a  debilitated  condition,  but  it 
is  sometimes  encountered  in  robust  young  men.  It  may  result  from 
leaving  the  bed  too  soon,  and  is  then  generally  confined  to  the  lower 
extremities.    It  is  not  usually  a  fatal  complication. 

4.  The  verrucose  eruption  is  a  rare  form  in  which  the  vesicles  par- 
tially dry  and  remain  adherent  to  the  skin,  particularly  on  the  face, 
resembling  horny  warts. 

A  crystalline  eruption  is  also  described  in  which  the  vesicles  rapidly 
dry  without  undergoing  pustulation. 

Malignant  Smallpox  (Variola  Maligna).— This  form  is  characterized 
by  profound  alteration  of  the  blood,  with  resultant  purpuric  or  hemor- 
rhagic eruptions  and  hemorrhages  from  the  mucous  membranes  and  into 
the  substance  of  various  organs.  Klebs,  Unna,  and  others  attribute 
the  cutaneous  hemorrhages  to  blocking  of  the  vessels  of  the  skin  by 
bacteria.  Another  explanation  is  that  an  acute  hemophilia  is  established 
through  a  dissolution  of  the  blood  by  the  infectious  agents  (hematolysis), 
and  hematin  is  deposited  in  the  substance  of  the  skin  and  other  tissues. 
In  some  cases  death  occurs  before  an  eruption  appears.  The  shotlike 
feel  of  the  skin  may  be  found  in  such  cases. 

The  onset  is  unusually  severe.  On  the  evening  of  the  second  or  third 
day,  as  a  rule,  a  diffuse  rash  appears  in  the  groin,  inner  surfaces  of 
the  thighs,  axillae,  or  one  of  the  other  regions  already  referred  to,  with 
small  punctiform  hemorrhages.  The  fever  is  usually  slight  or  it  may  be 
absent.  The  eruption  extends  and  soon  becomes  hemorrhagic;  ecchy- 
moses  appear  on  the  mucous  membranes,  including  the  conjunctiva;. 
Profuse  hemorrhages  from  various  sources,  as  the  nose,  mouth,  bowels, 
stomach,  kidneys,  even  from  the  eyes,  rapidly  sap  the  vitality  of  the 
patient.  The  face  becomes  enormously  swollen,  purple  in  color,  the  con- 
junctivae project  over  the  shrunken  cornea;.  Retinal  hemorrhages  fre- 
quently destroy  the  sight.  The  patient  rarely  survives  longer  than  the 
fifth  day.  The  mind  may  remain  clear  to  the  last;  as  Curschmann 
rem.arks,  "Only  a  few  patients  are  so  fortunate  as  to  fall  speedily  into 
delirium  or  coma." 

Varioloid  (variola  benigna)  is  a  form  of  smallpox  which  has  been 
rendered  mild  and    comparatively    harmless    by    previous    vaccination. 


2  62  PRACTICE  OF  MEDICINE 

rarely,  perhaps,  as  a  result  of  natural  insusceptibility  (x  a  previous 
attack  of  the  disease.  In  most  cases  the  disease  differs  from  true  small- 
pox only  in  the  lighter  character  of  the  symptoms,  but  cases  have  been 
described  in  which  the  eruption  failed  to  appear,  or  rapidly  underwent 
resolution  after  reaching  only  the  stage  of  papulation  or  vesiculation. 
Osier,  in  his  large  experience  at  Montreal,  failed  to  encounter  a  case 
without  eruption. 

The  invasion  may  be  severe,  with  chill,  headache,  backache,  vomiting, 
and  a  rapid  rise  of  temperature  to  103°  F.  (39.5°  C),  sometimes  higher. 
The  papular  eruption  appears  at  the  end  of  the  third  day,  and  the  tem- 
perature and  other  symptoms  recede.  The  papules  are,  however,  few  in 
number,  often  not  more  than  a  dozen,  mostly  on  the  face  and  hands, 
with  perhaps  one  here  and  there  over  the  trunk.  Vesiculation  and 
maturation  of  the  pustules  progress  rapidly,  and  there  is  usually  no 
second  rise  of  temperature.  Desiccation  begins  from  the  fifth  to  the 
seventh  day.  The  crusts  are  shallow,  and  pitting  does  not  usually 
remain. 

Complications  and  sequeloB  are  numerous.  Septicemia  and  pyemia, 
with  resultant  abscesses,  or  a  general  furunculosis,  are  not  uncommon, 
yet  more  so  than  might  be  anticipated  in  a  disease  attended  by  so  ex- 
tensive suppuration.  Fatal  pyemia  sometimes  develops  during  the  stage 
of  desiccation.  Pigmentation  of  the  skin  occasionally  remains  after 
the  disease.  A  second  (recurrent)  eruption  has  been  described.  Lobular 
pneumonia  is  a  frequent,  often  fatal  complication,  particularly  in  chil- 
dren ;  pulmonary  congestion  and  pleurisy  are  common  in  some  epidemics 
and  may  result  in  empyema;  lobar  pneumonia  is  rare.  The  laryngitis, 
so  commonly  present,  sometimes  leads  to  fatal  edema  of  the  glottis, 
rarely  to  necrosis  of  the  cartilages.  Myocarditis  is  the  most  frequent 
of  the  heart  complications  and  may  be  associated  with  endarteritis  of 
the  coronary  artery;  a  systolic  apex  murmur  may  be  heard  during  the 
height  of  the  fever.  The  initial  vomiting  rarely  persists;  diarrhea  is 
often  present;  parotitis  occasionally  develops.  Orchitis  and  ovaritis 
have  been  observed.  There  are  sometimes  sequelae  on  the  part  of  the 
nervous  system  during  convalescence;  cerebritis,  peripheral  neuritis, 
paraplegia,  and  other  paralyses  probably  due  to  peripheral  neuritis  or 
diffuse  myelitis,  optic  neuritis,  and  rarely  insanity,  are  encountered. 
Conjunctivitis  is  always  present  in  severe  cases;  retention  of  the  purulent 
secretion  often  leads  to  keratitis,  ulceration,  and  perforation;  iritis  and 
glaucoma  may  develop.  Otitis  media  sometimes  occurs.  Nephritis  is  sel- 
dom encountered,  although  albuminuria  is  often  present. 

Diagnosis. — Error  is  most  likely  to  occur  in  the  absence  of  a  known 
source  of  infection  or  when,  as  may  happen  in  varioloid,  the  initial 
symptoms  are  unusually  mild.  \^Tien  the  disease  is  prevalent,  the  histor}' 
of  a  chill  followed  by  high  fever,  103°  to  106°  F.  (39.5°— 41.0°  C), 
with  vomiting,  severe  headache,  and  lumbar  pain,  should  always  arouse 
suspicion  of  the  disease.  The  infections  most  likely  to  be  confounded 
with  smallpox  are  measles,  scarlatina,  and  chickenpox ;  typhus,  cerebro- 
spinal meningitis,  and  a  few  other  conditions  may  occasionally  be  sug- 
gested. 

In  measles  the  initial  symptoms  are  not  so  severe  and  the  temperature 
rises  gradually;  when  the  eruption  appears,  the  papules  are  soft  and 


SMALLPOX  263 

cannot  be  felt  when  the  skin  is  stretched,  as  can  those  of  smallpox.  In 
the  latter  disease,  coryza,  photophobia,  injection  of  the  conjunctivae, 
cough,  and  Koplik's  spots  are  all  absent.  The  initial  papular  eruption 
of  smallpox  is  sometimes  identical  with  that  of  measles. 

In  scarlet  fever  the  onset  is  sudden  with  high  temperature,  nausea, 
vomiting,  and  headache;  backache  is  not  usually  complained  of.  The 
initial  erythematous  eruption  of  smallpox  is  generally  pale  and  the 
strawberry  tongue  is  not  seen.  Scarlet  fever  is  more  uniformly  a  disease 
of  childhood. 

Chickenpox  is  distinguished  with  most  difficulty  from  varioloid,  particu- 
larly when  both  diseases  are  prevalent  at  the  same  time.  It  is  distin- 
guished by  the  character  and  location  of  the  eruption  and  the  course 
of  the  disease,  which  are  more  fully  considered  in  the  Diagnosis  of  Chick- 
enpox, page  267. 

Cerebrospinal  meningitis  resembles  smallpox  only  in  the  severity  of  the 
onset,  with  headache,  backache,  vomiting,  and  rapid  rise  of  temperature. 
It  may  be  excluded  by  the  rigidity  of  the  neck  muscles,  retraction  of 
the  head,  the  taches  cere'brale,  muscular  twitchings,  and  the  character 
of  the  eruption,  which  does  not  become  vesicular. 

Typhus  fever  closely  resembles  smallpox  in  its  invasion,  but  it  is  a 
much  less  frequent  disease ;  the  eruption  appears  on  the  chest  and  abdo- 
men, first  as  maculae,  which  later  become  converted  into  petechiae; 
they  do  not  give  the  sensation  of  shot  to  the  touch,  vesicles  and  pus- 
tules do  not  occur,  and  the  temperature  continues  to  rise  after  the  ap- 
pearance of  the  eruption. 

Glanders  has  been  mistaken  for  smallpox;  but  it  is  a  rare  disease, 
seen  only  in  those  caring  for  horses,  and  ulceration  very  speedily  occurs 
in  the  cutaneous  infiltration.    The  febrile  symptoms  are  much  the  same. 

Syphilis.— T\i^  areolar  and  pustular  eruptions  of  syphilis  have  been 
mistaken  for  variola.  The  history  of  the  disease,  absence  of  sudden 
invasion,  slight  if  any  elevation  of  temperature,  and  the  enlargement 
of  inguinal  glands,  generally  suffice  for  differentiation. 

Ptomain  poisoning,  with  high  fever,  vomiting,  diarrhea,  headache,  and 
an  erythematous  rash,  may  resemble  smallpox;  but  the  course  of  the 
affection  is  altogether  different  after  the  first  day,  and  the  cause  of  the 
poisoning  can  generally  be  discovered. 

Medicinal  rashes  rarely  cause  confusion.  That  of  potassium  iodid  may 
resemble  variola  pustules,  and  croton  oil  has  been  applied  with  intent 
to  deceive,  but  all  other  symptoms  are  absent. 

Prognosis.— The  mortality  in  persons  unprotected  by  vaccination 
is  25  to  35  per  cent,  sometimes  higher.  The  mortality  of  varioloid  is 
a  little  more  than  i  per  cent.  The  statistics  of  15,000  deaths  show 
the  following  rates:  Among  unvaccinated,  35  per  cent;  among  those 
having  one  vaccination  scar,  7.73  per  cent;  two  scars,  4.7  per  cent; 
three  scars,  1.95  per  cent;  four  or  more  scars,  0.55  per  cent.  Much  de- 
pends upon  the  character  of  the  epidemic,  the  constitution  and  age  of 
the  patient.  Children  under  five  years,  as  a  rule,  succumb.  The  malig- 
nant form  is  almost  universally  fatal;  cases  in  which  the  eruption  is 
purpuric  may  recover.  The  confluent  eruption  indicates  a  less  favorable 
prognosis  than  the  discrete,  and  the  gravity  of  the  disease  can,  as  a 
rule,  be  estimated  by  the  intensity  of  the  eruption  on  the  face  and  hands. 


264  PRACTICE  OF  MEDICINE 

When  the  fever  increases  after  the  appearance  of  the  eruption,  the  prog- 
nosis is  unfavorable.  Dehrium  and  convulsions  are  grave  symptoms. 
Severe  laryngitis  adds  danger  through  liability  to  the  development  of 
edema  of  the  glottis.  Pregnancy  renders  the  case  less  hopeful ;  abortion 
usually  occurs. 

Prophylaxis. — Effective  prophylaxis  can  be  secured  only  through  uni- 
versal, compulsory  vaccination.  The  disease  was  almost  eradicated  from 
Germany  by  the  vaccination  law  of  1874. 

As  soon  as  the  disease  is  suspected  in  a  case,  the  patient  should  be 
isolated.  It  is  generally  better  for  him,  and  always  safer  for  the  com- 
munity, to  have  him  placed  in  a  special  hospital.  Every  member  of  his 
household  should  be  immediately  vaccinated.  If  he  is  kept  at  home, 
a  large,  well-ventilated  room  should  be  prepared  by  the  removal  of  car- 
pet and  all  unnecessary  furniture  and  drapery.  Only  the  physician  and 
nurse  should  be  permitted  to  visit  the  patient.  The  physician  should 
protect  himself  from  the  danger  of  conveying  the  disease,  by  wearing  a 
linen  gown  and  oilcloth  cap,  and  he  should. make  his  visits  brief. 

The  urine,  feces,  and  all  discharges  should  be  disinfected  with  as 
much  care  as  those  of  typhoid  fever,  by  the  addition  of  mercuric  chlorid 
solution  (i  :5oo),  and  the  clothing  of  the  patient  and  nurse  should  be 
disinfected  by  steam  or  by  soaking  in  a  i  :2o  solution  of  carbolic  acid, 
followed  by  boihng.  All  utensils,  bedclothing,  everything  that  comes 
into  contact  with  the  patient  must  be  thoroughly  disinfected  or  de- 
stroyed by  fire  after  the  recovery  of  the  patient.  The  room  should 
also  be  thoroughly  disinfected  with  formaldehyd  vapor  for  24  hours, 
and  the  walls,  ceiling,  floors,  and  bed  should  be  scrubbed  with  corro- 
sive sublimate  solution,  i  :iooo. 

Treatment— The  diet  of  the  patient  should  be  of  the  most  nourishing 
character.  During  the  febrile  stage  it  must  be  liquid  in  form— milk, 
broths,  and  an  abundance  of  water,  lemonade  or  other  fruit-juices  in 
water.  During  the  remission  of  the  fever,  eggs,  toast,  and  soups  may  be 
added;  in  the  stage  of  suppuration,  stimulants  should  be  given  to  meet 
the  decline  of  strength.  Pledgets  of  ice  are  gratifying  and  soothing  to 
the  throat.  Ice-cream  may  be  allowed  when  the  stomach  will  tolerate 
it.  The  fever  and  prostration  may  be  counteracted  by  cool  baths  or 
cold  sponging;  antipyretics  should  be  administered  with  caution,  if  at 
all,  on  account  of  their  depressing  effect.  Vomiting  is  to  be  checked 
by  the  administration  of  champagne,  dilute  hydrocyanic  acid,  cocain, 
or  small  doses  of  calomel  in  the  absence  of  diarrhea.  Excessive  diarrhea 
may  be  controlled  by  the  camphorated  tincture  of  opium,  bismuth  01- 
lead  acetate  with  opium.  The  nervous  manifestations  call  for  the  bro- 
mids,  stimulation,  and  baths  of  70°  F.  (21.0°  C.)  or  cold  sponging 
repeated  as  often  as  the  temperature  rises  to  103°  F.  (39.5°  C).  Mor- 
phin  may  be  required  to  relieve  the  pains. 

TAe  Eruption.— lUnoks.  can  be  done  to  relieve  the  painfulness  of  the 
eruption,  and  many  measures  are  employed  to  limit  the  pitting.  Fre- 
quent bathing  with  a  i  15000  solution  of  corrosive  sublimate  or  i  :2o 
of  carbolic  acid  is  one  of  the  best  measures.  Hydrogen  peroxid  may  be 
employed  to  cleanse  away  the  pus.  The  addition  of  gylcerin  to  any 
of  these  solutions  is  recommended  by  some  writers.  Ichthyol  collodion 
is  probably  the  best  application  for  the  face  and  hands.     Masks  of  lint 


VACCINATION  265 

saturated  in  the  bichlorid  solution  should  be  constantly  worn  on  the 
face  and  hands  and  covered  with  oil-silk,  for  not  a  little  of  the  benefit 
to  be  derived  from  them  is  due  to  the  exclusion  of  light.  All  crusts, 
not  overlooking  those  of  the  nose,  should  be  kept  thoroughly  moist, 
and  scratching  should  be  prevented  by  restraint  of  the  hands  or  by 
thoroughly  enveloping  them  in  the  moist  lint.  Applications  of  oil, 
vaselin,  or  glycerin  to  the  crusts  are  preferred  by  some  authors.  The 
hair  should  be  closely  cut. 

The  eyes  must  be  carefully  looked  after  and  cleansed  three  or  four 
times  a  day,  irrigated  with  boric  acid  solution,  and  vaselin  should  be 
applied  to  prevent  adhesion  of  the  lids.  A  spray  of  corrosive  sublimate 
I  :iooo  has  been  recommended  for  use  in  the  nose,  mouth,  and  ears. 

In  the  hemorrhagic  form  of  the  disease,  nothing  can  generally  be 
done,  but  full  doses  of  ergot,  tincture  of  ferric  chlorid,  gallic  acid  or 
turpentine  may  be  tried.  Tracheotomy  may  be  resorted  to  when  edema 
of  the  glottis  develops.  During  convalescence,  the  patient  should  bathe 
often,  sponging  with  carbolic  acid  or  other  antiseptic  solution.  His 
danger  to  others  ceases  only  after  the  skin  has  become  entirely  free  from 
all  traces  of  crusts. 

VACCINATION. 

Definition. — The  artificial  production  of  immunity  to  smallpox  by  in- 
oculation with  the  virus  of  vaccinia,  or  cowpox. 

The  nature  of  vaccinia  has  not  been  determined.  Many  of  the  best 
authorities  regard  it  as  a  form  of  smallpox  modified  by  transmission 
through  the  body  of  the  cow,  while  others  look  upon  it  as  a  distinct 
disease. 

The  lymph  for  use  in  vaccination  is  obtained  from  vesicles  on  the 
udders  of  young  heifers  or  calves  before  the  lymph  has  become  turbid. 
The  virus  is  then  dried  on  ivory  "points"  or  hermetically  sealed  in 
glass  tubes.  The  danger  of  inoculating  with  other  diseases  by  the  use 
of  humanized  virus — lymph  obtained  from  a  child  after  vaccination, 
or  from  the  dried  crust — is  so  great  that  it  should  never  be  employed 
except  in  case  of  emergency.  When  this  arises,  the  lymph  should  be 
taken,  if  possible,  from  a  clear,  unbroken  vesicle  on  the  eighth  day  after 
vaccination,  the  utmost  care  being  exercised  to  obtain  it  from  a  robust, 
healthy  child  free  from  tuberculous  or  syphilitic  taint. 

The  Method. — The  place  selected  for  scarification  is  usually  on  the 
outer  side  of  the  left  arm  over  the  insertion  of  the  deltoid.  In  girls 
the  leg  is  sometimes  selected  for  esthetic  reasons.  This  is  then  cleansed 
and  rendered  aseptic.  The  skin  is  stretched  between  the  fingers  and  a 
spot  about  an  eighth  of  an  inch  in  diameter  is  scraped  with  a  clean 
lancet,  the  ivory  point,  or  a  needle  until  serum  begins  to  ooze.  Blood 
should  not  be  drawn.  The  charged  end  of  the  point  is  then  dipped  in 
clean  water  and  rubbed  over  the  scarification  until  the  coating  has 
been  removed.  It  is  advisable  to  continue  the  friction  until  a  slight 
blush  appears  in  the  adjacent  skin.  The  vaccination  is  allowed  to  dry 
before  the  clothing  is  adjusted.  After  the  arm  has  become  inflamed 
and  painful,  the  comfort  of  the  child  may  be  added  to  by  the  appli- 
cation of  a  shield  or  a  linen  patch  greased  with  white  vaseline  and 
covered  with  a  pledget  of  cotton.     In  case  the  pock  becomes  ruptured, 


266  PRACTICE  OF  MEDICINE 

the  arm  should  be  bathed  with  an  antiseptic  solution  to  prevent  inocu- 
lation of  the  surrounding  skin  by  the  pus  discharged  from  it.  In  the 
presence  of  an  epidemic  it  is  safer  to  scarify  two  or  three  places,  inocu- 
lating each  with  a  different  point,  unless  the  freshness  of  the  virus  is 
positive;  in  ordinary  cases  one  scarification  is  sufficient.  Infants  are 
usually  vaccinated  in  the  second  or  third  month ;  after  exposure  it  should 
be  done  immediately  without  regard  to  age.  A  child  should  be  vacci- 
nated not  later  than  the  tenth  year,  but  in  times  of  danger  it  is  better 
to  repeat  the  vaccination  at  any  time,  even  after  but  one  or  two  years 
have  elapsed,  until  three  or  four  successes  have  been  secured. 

Symptoms. — The  history  of  the  lesion  produced  by  vaccination  is  in 
a  measure  similar  to  that  of  a  single  smallpox  papule.  On  the  third 
or  fourth  day  after  vaccination,  a  small  red  papule  appears,  sur- 
rounded by  a  hyperemic  areola.  This  increases  in  size  until  the  fifth 
or  sixth  day,  when  it  changes  into  a  vesicle  with  a  depressed  center. 
The  vesicle  enlarges  and  the  umbilication  becomes  deeper  until  by  the 
tenth  day,  as  a  rule,  the  pustule  has  become  mature.  About  the  eleventh 
or  twelfth  day  the  hyperemia  begins  to  subside  and  desiccation  begins. 
The  scab  separates  about  the  21st  to  the  25th  day. 

The  constitutional  symptoms  are  usually  mild.  On  the  fourth  or  fifth 
day  there  is  often  a  slight  elevation  of  temperature,  which  may  persist 
for  a  few  days.  Nausea  and  vomiting  sometimes  occur.  The  Ij^mph- 
glands  nearest  to  the  site  of  vaccination  become  enlarged  and  sensitive. 

Irregular  Symptoms  and  Complications. — In  some  cases  the  formation 
and  progress  of  the  pock  are  unusually  rapid,  in  others  they  are  delayed 
beyond  the  usual  time.  Injury  of  the  sore  may  cause  unusual  inflam- 
matory extension  and  ulceration.  A  recurrence  of  the  pock  has  been 
seen  in  a  few  instances.  A  more  or  less  protracted  generahzed  pustular 
eruption  sometimes  occurs  and  has  proved  fatal  to  young  children 
(generalized  vaccinia).  An  eruption  of  vesicles  within  a  limited  area 
around  the  vaccination  is  not  unusual.  In  unhealthy  children  or  as  a 
result  of  uncleanliness  in  the  vaccination  or  in  the  subsequent  care  of 
the  arm,  deep  ulceration  occasionally  occurs;  lymphangitis  and  gan- 
grenous sloughs  sometimes  form  and  sepsis  may  develop.  Tetanus  is 
extremely  rare.  Among  the  infrequent  complications  are  erysipelas, 
urticaria,  erythema  multiforme,  eczema,  and  lichen.  Syphilis  has  been 
inoculated  by  the  use  of  humanized  virus.  That  tuberculosis  or  leprosy 
has  ever  been  conveyed  with  the  vaccine  has  not  been  definitely  shown. 

CHICKENPOX. 

VARICELLA. 

Definition. — An  acute,  contagious  disease  of  children,  characterized  by 
a  vesicular  cutaneous  eruption  and  mild  constitutional  disturbances. 

Etiology. — The  disease  is  highly  contagious,  often  becoming  epidemic, 
especially  in  schools  and  asylums.  Spring  and  autumn  are  the  seasons 
of  its  greatest  prevalence,  but  sporadic  cases  occur  at  any  time  of  the 
year.  The  specific  cause  is  not  known.  Although  peculiarly  a  disease  of 
childhood,  it  not  infrequently  attacks  adults.  It  is  in  no  way  related  to 
smallpox,  but  often  occurs  in  epidemic  form  shortly  before,  after,  or  dur- 


CHICKENPOX  267 

ing  an  epidemic  of  that  disease.    One  attack  usually  confers  immunity, 
but  recurrences  have  been  noted. 

Symptoms. — Incubation  lasts  from  ten  to  fifteen  days,  occasionally  a 
day  or  two  longer.    Slight  prodromal  indisposition  is  sometimes  noticed. 

In  mild  cases  the  invasion  is  not  attended  with  constitutional  dis- 
turbances, but  there  are  generally  an  elevation  of  temperature  to  100° 
or  102°  F.  (^Tf^° — 39°  C),  chilliness,  anorexia,  nausea,  perhaps  vomiting 
and  restlessness,  and  slight  muscular  pains.  The  eruption  usually  ap- 
pears within  24  hours,  on  the  face,  neck,  and  scalp;  it  later  becomes 
even  more  abundant  on  the  trunk  and  extremities,  particularly  on  the 
back.  It  consists,  at  first,  of  slightly  raised,  round  or  oval,  red  papules, 
which  within  a  few  hours  become  converted  into  clear  vesicles.  These 
vary  in  size  from  a  pinhead  to  a  dime;  the  largest  are  found  upon 
the  forehead  and  back;  the  total  number  varies  from  a  half-dozen  to 
two  hundred  or  more.  Distinct  umbilication  does  not  occur ;  but  by  the 
second  day,  sometimes  earlier,  the  tops  of  the  vesicles  become  flattened. 
They  become  purulent  within  36  to  48  hours.  They  are  not  surrounded 
by  a  distinct  areola,  but  the  external  zone  of  the  pustule  may  have  a 
dark  red  color,  particularly  after  it  has  been  ruptured  and  converted 
into  an  ulcer.  By  the  third  or  fourth  day  the  pustules  have  dried  into 
dark  brown  crusts  which  usually  become  detached  in  a  few  days  and 
leave  no  pits,  except  as  a  result  of  scratching.  Successive  crops  of  vesi- 
cles appear  in  most  cases,  so  that  it  is  not  unusual  after  the  third  day 
to  find  fresh  vesicles  among  the  drying  pustules.  The  mouth  is  some- 
times invaded  by  the  eruption,  but  the  vesicles  are  there  quickly  con- 
verted into  open  ulcers  by  the  saliva.  The  conjunctiva,  larynx,  and 
trachea  are  seldom  involved. 

The  temperature  does  not  always  decline  with  the  appearance  of  the 
eruption  as  in  variola.  The  only  prominent  symptom,  aside  from  the 
eruption,  in  most  cases,  is  the  itching,  which  is  sometimes  most  annoying. 
Anomalous  cases  occasionally  occur.  The  vesicles  maybe  extraordinarily 
large,  measuring  from  a  half  to  three-quarters  of  an  inch  in  diameter 
and  resembling  ecthyma  or  pemphigus.  In  rare  cases,  owing  to  infection 
from  the  finger-nails,  the  skin  around  the  ulcer  becomes  gangrenous. 
Cases  of  hemorrhagic  yaricella  have  been  described.  Complications  are 
few.  Erysipelas  has  been  observed;  the  lymph-glands  are  sometimes 
enlarged  and  may  suppurate;  nephritis  is  sometimes  observed,  and  death 
has  been  attributed  to  an  unusually  extensive  involvement  of  the  skin. 

Diagnosis. — The  differentiation  of  varicella  from  varioloid  is  often 
of  the  greatest  importance  and  is  sometimes  exceedingly  difficult.  It  is 
to  be  made  for  the  most  part  by  a  study  of  the  eruption,  although  the 
mild  stage  of  invasion  is  of  much  value.  In  varicella  the  greatest  num- 
ber of  vesicles  is  generally  found  upon  the  trunk.  The  vesicles  are  more 
superficial,  not  so  fully  globular,  may  be  oval,  are  not  umbilicated,  but 
rather  flat  in  the  center,  and,  when  punctured,  they  collapse.  The  original 
papules  have  not  the  shotlike  feel  of  variola,  and  it  is  usual  to  find 
recent  vesicles  distributed  among  the  pustules  and  crusts.  Initial  rashes 
are  occasionally  seen  in  varicella,  but  not  so  frequently  as  in  smallpox. 
The  eruption  is  never  confluent. 

Treatment. — The  disease  is  so  harmless  that  isolation  is  seldom  en- 
forced; it  is  safer,  however,  to  at  least  protect  delicate  children.      Con- 


268  PRACTICE  OF  MEDICINE 

finement  to  the  house  and  light  diet  should  be  ordered  during  the  exist- 
ence of  the  fever.  Internal  medication  is  unnecessary.  To  relieve  the 
itching,  the  skin  may  be  sponged  several  times  a  day  with  a  parbolic 
acid  solution,  i  :2o,  or  carbolated  vaselin  may  be  applied.  Anders  recom- 
mends the  application  of  ichthyol  (2  per  cent)  in  zinc  ointment  after 
the  crusts  have  formed.  Scratching  should  be  prevented  by  placing 
mittens  on  the  hands  if  necessary. 

PSOROSPERMIASIS. 

Psorosperms,  known  also  as  sporozoa  or  gregarinidae,  are  best  known 
as  they  occur  in  the  lower  animals,  for  they  have  been  rarely  found  in 
the  human  being.  In  some  instances,  small,  nucleated,  spherical  organ- 
isms, usually  termed  coccidia,  have  been  discovered  in  the  cells  of  the 
body,  especially  in  those  of  the  intestine,  spleen,  liver,  kidneys,  and  serous 
membranes.  They  produce  small  nodules  which  are  readily  mistaken  for 
tubercles.  In  the  liver,  indeed,  they  sometimes  form  palpable  tumors. 
Several  cases  of  peculiar  skin  disease  have  been  attributed  to  them,  and, 
on  the  other  hand,  several  diseases  formerly  so  regarded  have  more 
recently  been  referred  to  other  causes. 

Symptoms. — Internal  psorospermiasis  is  usually  attended  with  indica- 
tions of  local  disturbances  in  the  organ  affected,  pain  and  tenderness, 
sometimes  accompanied  with  diarrhea.  Peritonitis  may  be  produced. 
When  the  kidneys  are  affected,  there  is  hematuria.  The  disease  may 
prove  fatal  within  a  few  weeks,  or  it  may  last  for  several  years.  In 
the  cutaneous  cases  the  nodules  appear  first  upon  the  face  and  extend 
to  the  other  surfaces  of  the  body.  The  lymph-glands  and  lungs  are 
later  invaded,  as  a  rule,  and  often  contain  nodular  masses  in  which 
the  psorosperms  are  found. 

INFUSORIA. 

Quite  a  number  of  infusoria  have  been  discovered  within  the  body, 
but  they  are  for  the  most  part  harmless  and  not  productive  of  symp- 
toms. 

I,  The  cercomonas  intestinalis  is  a  pear-shaped  parasite  having  a 
sharp  anterior  extremity  provided  with  a  short  cilium,  and  a  broad 
posterior  extremity  to  which  is  attached  a  tail-like  fiagellum.  It  has 
been  discovered  in  connection  with  different  diarrheal  conditions,  but 
is  not  known  to  have  pathological  properties.  2.  The  cercomonas  coli 
hominis  was  observed  in  one  instance  by  May,  a  case  of  carcinoma  of 
the  stomach  with  chronic  diarrhea.  The  organism  is  about  as  large 
as  a  red  blood-cell,  spindle-shaped,  the  anterior  end  being  blunt  and 
provided  with  four  cilia.  3.  The  trichomonas  intestinalis  is  also  a  pear- 
shaped  organism  from  10  to  15/7.  long  and  ya  broad  and  endowed  with 
ameboid  movement.  It  is  found  in  diarrheal  discharges.  4.  The  tri- 
chomonas vaginalis  has  been  found  in  cases  of  vaginitis,  but  is  not 
known  to  bear  a  relation  to  the  disease.  It  is  smaller  than  that  found 
in  the  intestine. 

5.  The  trichomonas  flagellata,  caudata,  and  eiongata  have  been 
found  in  the  mouth  by  Sternberg.     Similar  flagellate  bodies  have  been 


TREMATODES  269 

seen  in  the  expectoration  from  gangrene  of  the  lung,  bronchiectasis,  and 
pleurisy. 

6.  The  balantidium  coli  is  an  ovoid  body  7  to  io,a  in  diameter 
and  surrounded  by  cilia.  Oral  and  anal  apertures  are  recognizable. 
Its  natural  habitat  is  in  swine.  Man  becomes  infested  through  contam- 
inated water  or  food.  It  has  been  found  in  diarrheal  and  dysenteric 
conditions,  but  is  not  known  to  be  the  cause  of  them.  The  megastoma 
entericum  has  also  been  seen  in  great  numbers  in  the  stools  of  chronic 
diarrhea. 

THE    TREMATODES. 

Disiomiasis  is  the  name  applied  to  the  diseases  produced  by  the 
trematodes  or  flukes,  several  of  which  are  found  in  man,  notably  :  ( i ) 
The  liver  flukes,  (2)  the  blood  flukes,  and  (3)  the  bronchial  flukes. 

1.  Liver  Flukes. — The  most  common  of  these  is  the  distoma  hepat- 
icum  (fasciola  hepaticum),  yet  Huber  found  only  22  cases  in  the  litera- 
ture of  over  a  hundred  years  prior  to  1896.  It  is  a  broad,  lanceolate 
body  from  28  to  32  mm.  in  length.  It  is  found  in  the  liver,  gall-blad- 
der, and  bile-ducts.  Its  intermediate  host  is  a  small  snail  which  crawls 
over  grass  and  water-cresses,  and  this  fact  probably  explains  its  occa- 
sional appearance  in  man,  and  much  greater  frequency  in  sheep.  The 
distoma  lanceolatum  is  a  smaller  parasite,  8  to  10  mm.  long.  It  has 
been  found  in  the  same  locations.  The  distoma  Buski  (or  D.  crassum)  is 
a  large  fluke  measuring  6  to  8  cm.  in  length.  Other  flukes  occasionally 
found  in  the  liver,  though  not  in  this  country,  are  the  distoma  Siber- 
icum,  D.  spatulatum  (or  sinense),  and  D.  conjunctum. 

Symptoms. — There  is  usually  some  indication  of  hepatic  and  intestinal 
irritation  and  chronic  cholangitis,  with  resultant  diarrhea,  enlargement 
of  the  liver,  jaundice,  and  sometimes  ascites.  Progressive  emaciation 
is  usually  observed.  The  eggs  are  frequently  found  in  the  dejections,  and 
the  parasites  sometimes  find  their  way  into  the  subcutaneous  tissue. 

2.  Blood  Flukes  (Distoma  Hematobium,  Hematobia  Bilharzia). — This 
is  a  flat  worm  with  the  two  sucking  disks  on  the  abdomen.  The  male  is 
shorter  and  thicker  than  the  female.  It  is  an  exceedingly  common  para- 
site among  the  children  in  Egypt,  and  it  is  believed  to  enter  the  body 
more  commonly  through  the  integument  while  the  individuals  are  bath- 
ing than  through  the  medium  of  drinking-water,  as  was  formerly  sup- 
posed. 

Symptoms. — The  portal  system  is  especially  affected.  The  eggs  are 
found  in  the  veins  of  the  small  intestine  and  rectum,  kidneys  and  blad- 
der. Micturition  is  painful,  and  blood,  pus,  and  the  sharp-pointed,  ovoid 
eggs  of  the  fluke  are  found  in  the  urine.  The  mucous  membranes  of 
the  renal  pelvis,  ureter,  and  bladder  are  much  thickened,  and  large  cal- 
culi are  sometimes  formed.  Leucocytosis  and  eosinophilia  have  been 
observed  in  at  least  two  instances. 

Treatment. — This  consists  in  the  administration  of  full  doses  of  male 
fern  or  thymol.  The  bladder  should  be  irrigated  with  a  i  :iooo  solution 
of  mercuric  chlorid. 

3.  Bronchial  Flukes.— The  distoma  pulmonale  (D.  Westermanni)  is 
common  in  Japan,  China,  and  Formosa,  where  the  disease  becomes 
epidemic.    It  has  probably  never  been  seen  in  this  country,  except  iu 


270 


PRACTICE  OF  MEDICINE 


the  cat  and  dog,  by  Ward  of  Nebraska.  It  is  8  to  10  mm.  long,  5  to 
6  wide,  club-shaped,  pointed  in  front,  blunt  behind.  It  has  the  color 
of  the  earthworm  and  the  movements  of  a  leech. 

The  symptoms  are  cough,  reddish-brown  sputum  containing  the  ova 
and  rarely  the  parasites. 

In  addition  to  these  trematodes,  several  others  have  been  encountered, 
notably  the  distoma  ophthalmobium  and  the  monostoma  lentis,  found 
in  the  eye;  distoma  heterophyes  and  amphistomum  hominis,  found  in 
the  small  intestine. 

Anneledes. — The  hirudinea,  or  leeches,  of  the  United  States  seldom 
cause  more  than  a  slight  temporary  disturbance  by  their  bites.  In 
Ceylon  and  certain  parts  of  South  America,  however,  large  ulcers  are 
frequently  produced  by  the  hirudo  Ceylonica ;  and  in  Europe  and  Africa, 
a  leech  known  as  the  herudo  vorax  attacks  the  mucous  membranes 
of  the  nose,  mouth,  larynx,  and  trachea,  producing  severe  inflamma- 
tions. 

DISEASES   CAUSED  BY  NEMATODES. 

ASCARIASIS. 

The  ascaris  lumbricoides  is  the  most  common  of  all  the  human 
parasites  and  is  particularly  frequent  in  children.  It  is  a  cylindrical 
worm,  pointed  at  both  ends,  and  of  a  yellowish  or  reddish  color.  The 
mouth  has  three  lips  and  the  body  is  marked  by  numerous  tranverse 
striations  and  four  longitudinal  bands.  The  female  is  usually  from  8 
to  12  inches  (20  to  30  cm.)  in  length.  The  male  is  shorter  and  is 
recognized  by  a  curved  caudal  extremity.  The  ova,  often  found  in 
great  numbers  in  the  feces,  are  broadly  elliptical,  about  0.05  mm.  long, 
and  surrounded  by  a  clear  albuminous  layer.  The  worm  contains  an 
odorous  substance  to  which  some  of  the  symptoms  are  thought  to  be 
due.  There  is  no  intermediate  host;  direct  transmission  and  develop- 
ment of  the  eggs  have  been  experimentally  demonstrated.  The  worm 
lives  in  the  small  intestine.  Only  one  or  two  are  generally  present,  but 
large  numbers  are  occasionally  found. 

Symptoms. — In  most  instances  no  symptoms  are  observed  which  can 
be  attributed  to  the  presence  of  the  worm.  In  other  instances  continued 
fever,  restlessness,  twitchings,  even  convulsions  are  regarded  as  due  to 
the  reflex  irritation  caused  by  large  numbers  or  to  the  absorption  of 
the  volatile  substance  produced  by  them..  Intestinal  symptoms,  inter- 
mittent diarrhea,  abdominal  pains,  and  foul  breath  are  sometimes  com- 
plained of.  Anemia  develops  in  prolonged  cases.  Such  symptoms  as 
itching  of  the  nose,  grinding  of  the  teeth,  and  talking  in  the  sleep  are 
always  associated  in  the  minds  of  mothers  with  the  presence  of  worms 
in  the  intestinal  canal. 

Disturbances  of  a  more  serious  nature  are  sometimes  caused  by  the 
migration  of  the  parasites  into  the  ducts  entering  the  intestine,  especially 
the  bile-duct  and  to  more  remote  parts.  The  pancreatic  duct  has  been 
entered,  intestinal  ulcers  have  been  perforated ;  and  there  is  little  doubt 
that  the  normal  intestinal  wall  has  been  perforated  by  them.  They  not 
infrequently  pass  up  to  the  stomach  and  may  be  vomited.    In  some 


TRICHINOSIS 


271 


instances  they  have  passed  through  the  esophagus  into  the  pharynx, 
Eustachian  tube,  or  larynx.  Fatal  asphyxia  has  followed  obstruction 
of  the  larynx;  bronchitis  has  followed  only  a  temporary  lodgment  in 
the  trachea,  when  the  worm  was  coughed  out,  and  gangrene  of  the 
lung  has  been  induced  by  their  lodgment  in  the  bronchi.  The  accumu- 
lation of  a  large  roll  of  worms  in  the  intestine  has  led  to  obstruction. 

Treatment. — Santonin  is  the  best  remedy.  It  is  given  to  a  child 
in  doses  of  gr.  ^^  to  j  (0.016 — 0.06),  or  gr.  ij  to  iij  (0.15  to  0.20) 
to  an  adult,  three  times  daily  for  two  or  three  days,  and  followed 
by  a  purge — calomel,  magnesium  citrate,  or  castor  oil.  Or  calomel,  gr. 
i-io  to  ^  (0.006 — 0.016),  may  be  combined  with  the  santonin.  The 
santonin  crystals  should  be  mixed  with  sugar  without  trituration,  since 
the  drug  is  then  less  likely  to  be  absorbed.  Such  disturbance  as  yellow 
vision  (xanthopsia)  is  seldom  observed,  but  the  urine  is  sometimes  dis- 
colored. 

Oxyuris  Vermicularis  (Thread-Worm,  Pin-Worm). — This  is  a  small, 
white,  threadlike  parasite.  The  length  of  the  female  is  i  o  mm.,  that  of 
the  male  4  mm.  It  is  found  at  any  age,  but  most  frequently  in  children. 
Its  habitat  is  the  rectum  and  colon.  Huber  asserts  that  the  male  is 
commonly  found  in  the  ileum.  Large  numbers  can  usually  be  detected 
in  the  feces  of  those  infested.  The  eggs  are  seldom,  if  ever,  found.  There 
is  no  intermediate  host,  and  the  eggs  or  the  parasites  themselves  are 
believed  to  be  transferred  directly  by  the  hands  of  their  host  to  others, 
and  possibly  through  the  medium  of  food  or  drink.  The  worms  migrate 
at  night  and  may  pass  out  of  the  rectum.  Great  numbers  are  frequently 
found  in  the  anus,  and  they  often  pass  into  the  vagina.  They  have 
been  found  also  in  the  nose  and  other  regions  whither  they  had  been 
carried  by  the  fingers  of  the  child. 

Symptoms. — The  most  frequent  symptom  is  pruritus,  which  becomes 
so  greatly  aggravated  at  night  by  the  wandering  of  the  worms  that 
the  child  becomes  restless,  sometimes  almost  frantic.  Convulsions  are 
occasionally  produced.  The  patient  may  become  anemic  and  emaciated. 
Perirectal  abscesses  have  been  induced  by  the  irritation  and  scratching. 
Many  nervous  disorders  have  been  attributed  to  the  parasite. 

Treatment. — All  that  is  necessary  in  most  cases  is  a  daily  enema 
of  a  cold,  strong  salt  solution,  or  of  infusion  of  quassia  or  aloes,  for 
ten  days.  In  some  casps  irrigation  of  the  bowel  with  solutions  of  car- 
bolic acid  or  turpentine  is  more  effective.  When  these  measures  fail, 
santonin  and  calomel  should  be  administered  per  os,  as  in  the  treatment 
for  lumbricoid  worms.  The  itching  may  be  relieved  by  the  application 
of  carbolated  vaselin  to  the  anus. 

Ascaris  Alata  (A.  mystax)  is  a  worm  from  2  to  3  inches  (4  to  8 
cm.)  long,  of  frequent  occurrence  in  the  dog  and  cat,  but  very  rare  in 
man. 

TRICHINOSIS. 

TRICHINIASIS. 

Definition. — A  disease  produced  by  the  embryos  of  the  trichina  spi- 
ralis in  their  migration  from  the  intestine  to  the  skeletal  muscles,  and 


272  PRACTICE  OF  MEDICINE 

characterized  by  pain,  tenderness,  and  swelling  of  the  muscles,  edema, 
and  fever. 

The  Parasite. — The  female  trichina  measures  3  or  4  mm.,  the  male 
1.5  mm.  The  latter  has  two  hooked  projections  from  the  posterior 
extremity.  The  body  is  surrounded  by  fine  striations,  and  around  the 
middle  portion  of  the  intestine  a  collection  of  large  cells  may  be  seen, 
which  is  of  value  as  a  diagnostic  feature.  The  mature  worm  inhabits 
the  intestine  of  man  and  of  many  of  the  lower  animals,  especially  swine 
and  rats. 

The  larval  trichina  is  from  0.6  to  i  mm.  in  length  and  is  best  known 
as  it  Ues  coiled  in  its  capsule  between  the  muscle  fibers.  The  capsule 
is  a  clear,  translucent  m^erabrane  produced  as  a  result  of  the  irritation 
set  up  by  the  presence  of  the  parasite.  In  the  course  of  time  it  becomes 
calcified.  In  this  condition  the  trichinae  remain  dormant,  but  retain 
their  vitality  for  many  years. 

Man  becomes  infested  through  eating  meat  containing  the  living 
larvae.  These  are  liberated  through  digestion  of  the  capsule  by  the 
gastric  juice,  and  pass  into  the  small  intestine.  Here  they  acquire  their 
full  growth  and  become  sexually  mature  in  about  three  days.  By  the 
end  of  five  days  living  embryos  are  found  in  the  intestine.  The  trichina 
is  viviparous,  the  female  giving  birth  to  several  hundred  living  young, 
possibly  to  successive  broods,  during  the  five  weeks  of  her  life.  But, 
although  living  embryos  are  found  in  the  intestine,  it  is  believed  that 
those  which  eventually  reach  the  muscles  are  born  in  the  lymph-spaces 
of  the  intestinal  wall  and  mesentery,  especially  in  the  Peyer's  patches 
and  mesenteric  glands,  since  the  impregnated  female  is  known  to  pass 
out  of  the  intestine,  and  the  embryos  have  been  found  in  large  numbers 
in  these  places.  Through  the  lymph  circulation  they  pass  into  the  blood, 
and  with  it  they  are  carried  to  the  muscles  of  all  parts  of  the  body. 
From  the  intermuscular  connective  tissues  they  pass  into  the  fibers,  where 
they  reach  their  full  growth  in  about  two  weeks.  The  capsule  is  formed, 
no  doubt,  as  a  result  of  the  interstitial  myositis  produced  by  the  irrita- 
tion of  their  presence.  A  single  embryo  is  usually  found  within  each 
capsule,  but  occasionally  there  are  three  or  four.  The  formation  of  the 
capsule  requires  about  six  weeks.  The  calcification  is  a  later  change, 
sometimes  seen  as  early,  however,  as  the  fourth  or  fifth  month  after 
the  invasion.  It  at  first  affects  only  the  extremities  of  the  capsule,  but 
later  involves  the  entire  sac  and  sometimes  the  embryo.  Every  stage 
in  the  life  cycles  of  the  trichina  may  be  studied  from  Plate  VIII. 

The  common  source  of  human  infection  is  the  meat  of  the  hog.  Raw 
or  insufficiently  cooked  pork  and  sausage  are  the  usual  forms  in  which 
this  is  eaten.  The  danger  is  removed  by  submitting  the  meat  to  a 
boiling  temperature.  The  disease  has  assumed  epidemic  form  in  a  num- 
ber of  instances,  all  the  cases  originating,  as  a  rule,  from  one  source. 
Three  hundred  persons  have  been  simultaneously  affected.  Such  out- 
breaks have  generally  occurred  in  Germany,  where  the  custom  of  eating 
raw  ham  and  sausage  prevails. 

Morbid  Anatomy. — The  changes  are  found  in  the  voluntary  muscles. 
The  number  of  parasites  is  enormous.  When  death  has  occurred  in  the 
fourth  week,  they  are  found  mostly  in  the  head  and  trunk;  after  the 
sixth  week,  also  in  the  extremities.    They  are  numerous  in  the  intestinal 


I 


EXPLANATION  OF  PLATE  VIII. 

Fig.  I. — Muscle  Trichina  enclosed  in  a  fully  developed  cyst,  X  240.  Cy, 
cyst:  B^,  connective  tissue  envelop;  /^k,  fat  globules. 

Fig.  2. — The  trichina  removed  from  the  cyst,  X  400.  Oe,  esophagus ;  Z/i, 
cell  bodies  ;  Z,  side  lines  ;   Ov,  ovary ;   Ck  D,  chyle  duct. 

Fig.  3. — Part  of  the  ovary,  X  600.  The  ovary  is  readily  distinguished  from 
the  testicle  by  the  varying  size  of  the  germ  cells. 

Fig.  4. — Male  intestinal  trichina,  X  100.  7^'.  testicle;  de/\  ejeculatory  duct; 
Z  /:,  cell  bodies. 

Fig.  5. — Female  intestinal  trichina,  X  go.  Ov,  Ovary;  is,  embryos;  Oe, 
genital  opening  from  which  the  embryos  escape. 

Fig.  6. — Free  embryo,  X  400.     (9,  mouth  ;  A,  anus. 

Fig.  7. — Embryo  about  three  days  after  having  entered  the  muscle  fiber. 
M/^,  normal  muscle  fiber. 

Fig.  8. — Muscle  trichina  about  six  days  old,  in  the  greatly  swollen  sarco- 
lemma  sheath  traversed  by  capillary  vessels.  Cap. 

Fig.  9. — Muscle  trichina  four  weeks  old,  enclosed  in  a  capsule.  Cf  A, 
within  the  sarcolemma  sheath,  Sk ;  Bk,  the  connective  tissue  capsule  in  process 
of  active  growth;  /^,  nuclei;  ^^,  contents  of  the  sarcolemma  sheath  at  each 
pole  of  the  capsule. 

Fig.  10. — Muscle  trichina  with  calcified  capsile ;  /^k,  fat  globules. 


Practice  of  Medicine.— French. 


PLATE  VIII. 


{Original  drawing hy  C.  Clans,  "Twentieth  Century  Practice.") 
TRICHINA  SPIRALIS. 


TRICHINOSIS 


273 


contents.  The  mesenteric  glands  are  enlarged;  the  muscles  grayish  or 
brownish  red.  The  degenerative  changes  are  seen  in  longitudinal  streaks 
from  0.5  to  2  mm.  in  length.  Bronchitis,  hypostatic  congestion,  and 
pneumonia  may  be  found.    The  heart  muscle  is  very  rarely  involved. 

Symptoms. — The  clinical  history  of  trichinosis  may  be  divided  into 
two  periods,  t\\e  Jirst  embracing  the  disturbances  occasioned  by  the  in- 
testinal trichinae,  the  second  those  accompanying  the  general  dissemina- 
tion of  the  larvae  in  the  muscles-  The  severity  of  each  stage  varies  with 
the  number  of  parasites  present.  The  gastrointestinal  disturbances 
generally  begin  on  the  second  or  third  day  after  the  ingestion  oftrichi- 
nous  flesh.  They  are  nausea,  vomiting,  colic,  and  diarrhea.  They  may 
be  so  mild  as  to  attract  little  attention  or  so  severe  as  to  simulate 
cholera  morbus.  Obstinate  constipation  often  follows  the  primary  diar- 
rhea. Accompanying  these  symptoms  there  is  always  a  sense  of  extreme 
weariness  like  that  which  follows  unusual  muscular  exercise.  All  these 
manifestations  usually  disappear  within  a  few  days. 

Second  Period. — Sometime  within  the  first  six  weeks,  almost  always 
between  the  seventh  and  tenth  day,  the  symptoms  of  invasion  begin. 
They  are  sometimes  initiated  with  a  chill  and  rise  of  temperature.  As 
the  myositis  is  developed,  the  muscles  become  swollen,  stiff,  hard  as 
rubber,  sensitive  to  pressure  and  motion,  sometimes  painful  at  rest. 
The  flexor  muscles  are  usually  affected.  Flexures  often  occur  which  bend 
the  elbows  and  knees  at  an  acute  angle.  The  involvement  of  the  dia- 
phragm and  intercostal  muscles  causes  urgent  dyspnea;  and  when  the 
muscles  of  mastication  and  those  of  the  larynx  are  invaded,  mastication 
and  deglutition  become  difficult  and  painful,  and  hoarseness  is  usually 
produced. 

The  fever  is  variable.  The  temperature  may  remain  normal  even 
when  the  muscles  are  extensively  invaded;  it  may  reach  only  102°  F. 
(39.0°  C.)  or  it  may  rise  to  104°  or  106°  F.  (40.0°  to  41.0°  C).  It  is 
then  usually  intermittent  or  remittent  in  its  course,  which  ordinarily 
lasts  from  four  to  seven  weeks.  In  mild  cases,  especially  in  children, 
it  may  be  of  shorter  duration,  and  the  muscular  pains  and  flexures  may 
also  abate.  In  extreme  cases  they  may  last  for  two  or  three  months. 
Profuse  sweating  occurs  during  the  febrile  stage,  and  sudamina  often 
develop.  Tingling  and  itching  of  the  skin  and  such  other  eruptions 
as  urticaria,  acne,  herpes,  or  furunculosis  are  not  uncommon.  In  pro- 
tracted cases  the  tongue  becomes  dry,  as  in  typhoid  fever. 

Edema  is  one  of  the  most  characteristic  symptoms  after  the  seventh 
day.  It  appears  in  the  face,  especially  the  eyelids,  and  lasts,  as  a  rule, 
from  two  to  five  days.  It  may  reappear.  The  extremities  become 
edematous  when  the  muscular  swelling  is  at  its  height,  sometimes  earlier. 
It  does  not  always  subside  with  the  swelling.    Ascites  may  develop. 

The  blood-count  usually  shows  marked  leucocytosis,  often  reaching 
30,000,  and  about  half  the  leucocytes  in  many  cases  are  eosinophiles, 
but  this  feature  is  probably  not  so  nearly  universal  as  at  first  supposed. 

Persistent  insomnia  occurs  in  severe  cases.  Headache  is  common, 
but  delirium  is  rare.  The  tendon  reflexes  are  often  lost,  and  tremors 
are  sometimes  noticed.  Mydriasis  has  been  observed.  The  patient 
becomes  markedly  anemic  and  emaciated.  Bronchitis  is  common,  and 
in  fatal  cases  pneumonia  and  pleurisy  are  sometimes  found.     Polyuria 


274  PRACTICE  OF  MEDICINE 

occurs  in  some  instances,  while  in  others  the  urine  becomes  scant,  of 
deep  red  color,  containing  albumin  and  sometimes  casts  and  red  blood- 
cells. 

Diagnosis.— "^  The  disease  should  always  be  suspected  when  a  large 
birthday  party,  or  Fest,  among  Germans  is  followed  by  cases  of  apparent 
typhoid  fever"  (Osier).  The  early  nausea  and  vomiting  are  not  charac- 
teristic, but  if  they  have  followed  the  eating  of  raw  pork  they  should  arouse 
suspicion.  The  diagnosis  can  often  be  confirmed  by  an  examination  of  a 
remnant  of  the  meat.  Trichinae  can  often  be  found  in  the  stools.  After 
the  seventh  day,  the  edema  of  the  face,  the  dyspnea,  the  swollen,  hard, 
tender,  contracted  muscles  leave  little  doubt  as  to  the  character  of  the 
disease.  A  small  fragment  of  muscle  may  be  removed  under  cocain 
anesthesia  with  a  harpoon  devised  for  the  purpose,  or  through  a  small 
incision.  The  parasites  are  most  numerous  near  the  tendinous  portion 
of  the  muscle. 

Typhoid  fever  is  excluded  by  the  painfulness  of  the  condition,  and  more 
particularly  by  the  leucocytosis. 

Acute  rheumatism  affects  the  joints,  while  the  swelling  and  soreness 
of  trichinosis  are  confined  to  the  muscles. 

Ptomain  poisoning  produces  gastrointestinal  disturbance  like  that  of 
trichinosis,  but  all  the  symptoms  develop  earlier  and  with  greater  vio- 
lence, as  a  rule.  The  skin  is  dry,  the  muscles  are  not  swollen  or  flexed, 
and  edema  is  absent. 

Cholera  morbus  is  usually  of  longer  duration  and  more  violent  than 
the  diarrhea  of  trichinosis,  and,  although  it  is  accompanied  with  pros- 
tration, there  is  not  the  sense  of  muscular  fatigue. 

Pseudotrichinosis. — A  considerable  number  of  reports  have  been  pub- 
lished of  the  finding  of  other  nematodes  closely  resembling  the  trichina, 
in  man,  lower  animals,  and  vegetables.  The  differentiation  can  usually 
be  made  by  observing  the  spiral-like  striations  and  the  group  of  large 
cells  about  the  middle  of  the  intestine  of  the  worm. 

Prognosis. — All  depends  upon  the  severity  of  the  attack  and  the 
number  of  the  parasites.  In  some  outbreaks  the  mortality  has  not 
exceeded  2  per  cent,  in  others  it  has  reached  30  per  cent. 

Prophylaxis. — Care  should  be  exercised  in  the  feeding  of  swine.  They 
should  not  be  given  the  refuse  of  slaughter-houses,  and  rats  should  be 
excluded  from  their  pens.  The  curing  and  smoking  of  the  meat  cannot 
be  relied  upon.  Only  thorough  cooking,  by  which  all  parts  of  the  meat 
are  raised  to  the  boiling  point,  will  prevent  the  infection.  Systematic 
inspection  of  meat  is  advisable  and  desirable  from  an  esthetic  point  of 
view,  but  it  cannot  take  the  place  of  cooking.  Pork  and  sausage  should 
never  be  eaten  raw. 

Treatment. — When  the  character  of  the  gastrointestinal  disturbance 
is  recognized  early,  a  promptly  acting  purge  will  often  remove  all  danger. 
All  the  anthelmintic  preparations  have  been  recommended,  especially 
santonin,  male  fern,  thymol,  and  turpentine.  Sodium  sulphocarbolate 
or  salicylic  acid  in  frequent  doses  in  keratin  capsules  may  be  employed. 
Glycerin  in  large  doses  is  always  mentioned,  but  it  is  inferior  to  the 
other  remedies.  A  free  action  of  the  bowels  should  be  maintained  until 
microscopic  examination  of  the  dejections  no  longer  reveals  the  para- 
sites.    After  the  invasion  of  the  muscles  has  begun,  the  treatment  is 


ANKYLOSTOMIASIS  275 

purely  symptomatic.  The  pain  and  soreness  of  the  muscles  may  be 
mitigated  by  the  application  of  ice-bags  or  hot  water.  Sleep  should 
be  secured  with  remedies  that  do  not  constipate,  as  trional  in  doses 
of  gr.  XV  to  XXX  (i.o — 2.0).  Tonics  may  be  required  later  to  overcome 
the  anemia  and  emaciation,  and  passive  motion  or  massage  to  restore 
the  muscles. 

ANKYLOSTOMIASIS. 


DOCHMIASIS,     TUNNEL-ANEMIA,     BRICKMAKER'S,    MINER'S,    OR     MOUNTAIN 
ANEMIA,  EGYPTIAN  CHLOROSIS. 

This  disease  is  produced  by  a  parasite  with  many  aliases,  the  an- 
kylostomum  duodinale;  dochmius,  strongylus,  or  uncinaria  duodinalis, 
etc.  It  is  a  nearly  cylindrical  worm,  from  ^  to  ^  inch  (6  to  18  mm.) 
long,  the  male  much  smaller  than  the  female.  It  is  yellow  or  gray,  and 
becomes  red  when  it  is  filled  with  blood.  The  head  is  bent  backward. 
The  mouth  is  provided  with  a  row  of  hooks  by  which  it  attaches  itself 
to  the  intestine.  The  male  has  a  large  bursa  copulatrix  at  its  hinder 
extremity.  The  upper  parts  of  the  small  intestine,  especially  the  duode- 
num and  jejunum,  are  its  habitat.  The  eggs  are  oval  and  measure  about 
60/Z  by  35,a.  These  mature  outside  of  the  body  under  favorable  con- 
ditions of  temperature,  and  the  larvae  become  encysted.  Thus  they 
reach  the  drinking-water  or  food  of  man,  and  the  cycle  is  completed. 
Some  investigators  assert  that  the  larvae  can  pass  through  the  integu- 
ment. 

Symptoms. — These  vary  with  the  stage  of  the  disease,  the  age,  sex, 
and  constitution  of  the  patient.  In  the  beginning  there  is  often  only 
such  gastrointestinal  disturbance  as  diarrhea  and  colic,  but  profound 
anemia  is  the  characteristic  symptom.  It  may  develop  so  rapidly  as  to 
cause  dyspnea  and  edema.  The  skin  is  yellowish  or  perhaps  blanched 
as  though  from  hemorrhage,  and  there  are  great  weakness  and  pros- 
tration, with  rapid  pulse  and  palpitation.  Moderate  fever  may  be 
present.  Emaciation  is  often  absent  except  in  advanced  cases.  All 
these  symptoms  are  the  result  of  the  abstraction  of  blood  by  the  par- 
asite, although  the  additional  influence  of  a  toxic  substance  secreted  by 
it  has  been  suggested.  Hypertrophy  and  dilatation  of  the  heart  are 
found  in  many  cases,  the  apex  being  displaced  downward  and  to  the 
left. 

Diagnosis. — An  early  diagnosis  is  important.  It  is  to  be  based  upon 
the  rapid  development  of  the  profound  anemia  accompanied  by  gastro- 
intestinal disorders,  and  confirmed  by  the  discovery  of  the  ova  in  the 
stools,  especially  in  tropical  countries  where  the  disease  is  most  preva- 
lent. Delamere  has  called  attention  to  a  peculiar  mark  on  the  tongue 
which  looks  as  if  the  patient  had  just  wiped  a  penful  of  blue-black  ink 
on  it.    He  found  it  an  early  and  constant  sign. 

Treatment. — Spontaneous  recovery  sometimes  occurs  owing  to  the 
death  of  the  parasites.  Thymol  is  a  specific.  It  should  be  given  in  two 
doses  of  3  ss  to  3  ij  (2.0  to  7.5)  two  hours  apart,  preferably  in  the 
morning,  the  first  dose  preceded  and  the  second  followed  by  a  purge  of 


2  76  PRACTICE  OF  MEDICINE 

magnesia  or  castor  oil.  The  treatment  may  be  repeated  in  a  week  if 
necessary.  During  treatment  the  patient  should  remain  in  bed,  on  a 
milk  diet,  and  no  alcoholic  beverages  should  be  allowed   (Guiteras). 

FILARIASIS. 

Definiiion. — A  diseased  condition  caused  by  the  filaria  sanguinis 
hominis  and  manifested  in  many  quite  different  lesions.  The  disease 
occurs  chiefly  in  tropical  and  subtropical  countries,  but  is  occasionally 
encountered  in  the  Southern  States.  It  is  very  prevalent  in  some  of  the 
West  India  islands.  Its  distribution  to  different  regions  of  the  globe  is 
shown  in  the  accompanying  map  (Plate  IX). 

The  Parasite. — No  less  than  six  species  of  the  filaria  have  been  de- 
scribed, but  only  three  of  these  have  been  sufficiently  investigated  to 
receive  general  recognition. 

(i)  Filaria  Sanguinis  Hominis  Noctiirna  (Filaria  Bancrofti). — This  is 
the  form  commonly  present.  The  mature  worm  is  about  as  thick  as 
a  human  hair;  the  female  is  from  3  to  4  inches  (S — 10  cm.)  in  length, 
the  male  is  a  little  more  than  half  as  long,  and  its  tail  has  a  spiral 
twist.  The  embryos  are  inclosed  in  a  sheath  and  measure  from  270 
to  34o,a  in  length  and  from  7  to  11//.  in  width.  They  are  found  in 
the  blood  at  night,  or  whenever  the  individual  sleeps.  The  intermediate 
host  of  this  species  and  probably  of  the  others  is  the  mosquito.  They 
have  been  found  in  several  species  of  the  culex  and  in  one  anopheles. 

(2)  Filaria  Sanguinis  Hominis  Diurna. — The  identity  of  this  species 
rests  upon  the  observation  of  it  by  Manson  in  the  blood  of  three  negroes 
from  the  Congo  region.  They  were  found  in  the  blood  only  during  the 
daytime.  They  are  further  distinguished  by  a  granular  body.  Manson 
regards  the  filaria  loa  as  probably  the  mature  form. 

(3)  Filaria  Persians. — Only  the  embryos  of  this  form  are  known,  £ind 
they  are  found  in  the  blood  both  day  and  night.  They  are  smaller, 
more  active  than  the  former,  and  have  no  sheath.  A  mature  worm  has 
been  described  by  Daniels  as  the  supposed  parent.  Manson  attributes 
to  this  form  the  sleeping  sickness  of  the  Congo  country  and  possibly 
also  craw-craw,  a  cutaneous  disease  of  the  west  coast  of  Africa. 

The  filaria  Bancrofti  has  been  most  thoroughly  studied.  The  mature 
parasite  has  been  found  in  the  human  body  only  about  eleven  times. 
These  were  found  for  the  most  part  in  the  lymph-channels,  adipose  tissue, 
or  in  abscesses  induced  by  their  presence.  The  female  gives  birth  to  a 
large  number  of  embryos  which  pass  with  the  lymph  into  the  blood. 
When  the  individual  is  active,  they  are  believed  to  remain  quiet  in  the 
blood-vessels,  especially  within  the  lungs.  When  the  individual  rests, 
they  wander  into  the  peripheral  circulation.  Hence  they  are  found  in 
increasing  numbers  from  evening  to  morning,  and  disappear  entirely 
by  9  a.  m.  Their  life  cycle  is  completed,  as  previously  stated,  through 
the  medium  of  the  mosquito.  They  are  extracted  with  the  blood  of 
their  host  into  the  body  of  the  insect.  Here  they  undergo  partial  de- 
velopment. It  is  assumed  that  after  the  death  of  the  mosquito  they 
are  liberated  in  the  water,  where  they  become  mature  and  again  enter 
the  body  of  man  through  the  drinking-water.     From  the  intestine  they 


Practice  of  Medicine.— French. 


PLATE  IX. 


CHARTS    SHOWING    DISTRIBUTION    OF    GUINEA    WORM 
AND    FILARIA    SANGUINIS    HOMINIS. 


( Twentieth  Century  Practice 


DRACHONTIASIS  277 

find  their  way  into  the  lymph-channels.  They  may  be  present  in  the 
body  indefinitely  without  producing  symptoms,  and  have  been  repeat- 
edly found  in  the  blood  of  animals  in  which  they  produced  no  recogniz- 
able disturbance.  When,  however,  the  mature  parasite  or  the  ova 
obstruct  a  lymph-vessel,  disturbances  are  produced  peculiar  to  the  loca- 
tion of  the  obstruction. 

Symptoms. — The  principal  manifestations  are  the  following  : 

(<z)  Hcniatochylu7-ia. — This  feature  is  manifested  by  an  occasional 
passage  of  a  milky,  bloody,  or  chylous  fluid  which  generally  deposits 
a  reddish  clot.  The  urine  may  continue  normal  in  quantity  or  it  may 
be  increased.  The  general  health  is  not  impaired.  The  condition  is 
intermittent  and  may  persist  for  many  years,  intervals  of  several  weeks 
often  intervening  between  the  chylous  discharges.  Microscopical  exam- 
ination of  the  chylous  urine  reveals  large  quantities  of  granular  fat, 
usually  red  blood-corpuscles,  and  sometimes  the  embryos.  It  is  well 
to  remember  that  the  anguillula  aceti  has  been  mistaken  for  the 
filaria  in  urine  not  chylous  in  character,  after  it  had  been  placed  in 
a  bottle  previously  used  to  contain  vinegar.  The  greatest  inconvenience 
is  usually  due  to  the  obstruction  caused  by  the  formation  of  clots 
within  the  bladder.  A  nonparasitic  form  of  chyluria  is  occasionally 
met  with. 

(Ji)  Lymph- Scrotum. — The  scrotum  becomes  distended  with  the  en- 
larged lymph-vessels  which  may  usually  be  traced  a  considerable  distance 
upward.  The  scrotum  may  be  much  thickened.  The  chylous  fluid  flows 
freely  from  punctures,  and  the  filariae  are  found  in  it.  Lymph-vulva 
was  observed  in  one  instance  by  Balz. 

(jT)  Other  Diseases. — The  filariae  have  been  found  also  in  other  con- 
ditions, among  which  are  elephantiasis  arabum,  chylous  ascites,  filarial 
hemoptysis,  and  chylous  diarrhea. 

Febrile  attacks  are  frequently  observed  during  the  course  of  many  of 
these  affections. 

Prophylaxis. — In  countries  where  these  diseases  are  prevalent,  all 
drinking-water  should  be  filtered  or  boiled. 

Treatment.— There,  is  no  known  means  of  destroying  either  the  ma- 
ture worm  or  the  embryos.  The  death  of  the  parasite  may  or  may 
not  be  followed  by  relief  of  the  obstruction.  The  remedies  which  have 
proved  most  beneficial  are  gallic  acid,  quinin,  and  the  barks  of  various 
tropical  trees.  When  chyluria  is  present,  the  patient  should  abstain  from 
fatty  food.  In  most  cases,  however,  little  can  be  done  beyond  the  treat- 
ment of  the  local  condition. 

DRACHONTIASIS. 

GUINEA-WORM   DISEASE. 

This  disease,  due  to  the  filaria  medinensis,  dracunculus  Persarum,  or 
Guinea-worm,  is  most  prevalent  in  the  East  Indies  and  in  Africa,  but  it  is 
occasionally  encountered  in  the  United  States,  for  the  most  part  among 
foreigners  (Plate  IX.).  The  living  male  has  been  found  only  once,  by 
Charles,  in  the  mesentery.    The  female  is  cylindrical,  20  to  40  inches  (50 — 


278  PRACTICE  OF  MEDICINE 

100  cm.)  in  length,  ^^  inch  (2  cm.)  in  diameter,  and  of  a  whitish  color. 
Only  one  parasite  is  usually  present.  The  avenue  of  entrance  is  probably 
in  all  cases  the  alimentary  canal,  and  the  medium  drinking-water.  It 
is  probable  also  that  the  male  accompanies  the  female,  and  with  her 
passes  out  of  the  intestine  into  the  mesentery,  and  that,  after  performing 
his  sexual  function,  he  dies.  Charles  found  calcified  remains  of  males 
in  the  mesentery.  The  female  passes  on  through  the  tissues  until  she 
reaches  the  subcutaneous  connective  tissue.  Here  she  remains  quiescent 
for  an  indefinite  time,  coiled  up  like  a  tangled  cord  beneath  the  skin. 
As  the  time  for  parturition  approaches,  at  least  with  an  evident  purpose 
of  liberating  her  embryos,  she  usually  travels  downward  until  she  reaches 
the  ankle  or  foot;  then  thrusts  her  head  through  the  overlying  skin. 
The  opening  is  occasionally  made  in  the  upper  parts  of  the  body.  A 
vesicle  is  formed  by  the  elevation  of  the  epidermis  over  the  head.  This 
finally  bursts  and  a  small  ulcer  is  formed,  at  the  bottom  of  which  the 
protruding  head  may  be  seen.  In  a  short  time  the  uterus  ruptures, 
for  there  is  no  other  way  of  liberating  the  young,  and  these  are  dis- 
charged in  a  milky  fluid.  Those  which  find  their  way  into  water  find 
an  intermediate  host  in  the  cyclops,  a  small  crustacean.  The  parent 
worm  soon  leaves  the  body  after  the  discharge  of  her  embryos. 

Treatment. — Prophylaxis  consists  in  preventing  the  entrance  of  the 
embryos  by  filtration  or  boiling  of  drinking-water.  The  worm  should 
not  be  molested  when  it  first  makes  its  appearance  beneath  the  skin, 
since  it  is  then  seeking  an  avenue  of  escape  from  the  body.  It  is  cus- 
tomary in  the  tropics  to  roll  the  body  of  the  worm  around  a  smooth 
stick  as  it  protrudes,  winding  a  httle  more  each  day,  but  serious  in- 
flammation follows  the  rupture  of  the  body.  The  worm  has  been  excised 
entire  with  success,  but  a  better  method  for  causing  its  destruction  is 
the  injection  of  mercuric  chlorid,  i  :  1000.  Asafetida  in  large  doses  has 
been  vaunted  as  a  specific. 


OTHER  NEMATODES. 

The  following  nematodes  have  been  found  once  or  more  within  the 
human  body :  Filaria  labialis,  F.  bronchialis,  F.  hominis  oris,  F. 
lentis,  their  names  signifying  their  location ;  the  filaria  immitis,  causing 
hematuria,  found  also  in  the  portal  vein,  and  its  ova  in  the  walls 
of  the  ureter  and  bladder;  and  the  filaria  loa,  found  beneath  the  con- 
junctiva. 

Eustrongylus  Gigas  (Dioctophyme  Gigas). — This  is  a  large  worm, 
the  female  measuring  20  to  40  inches  (50  to  100  cm.),  the  male  about 
one-third  as  long.  It  is  found  especially  in  the  kidneys  of  the  lower 
animals,  and  only  rarely  in  man.  Hematuria  is  produced  and  some- 
times the  entire  kidney  is  destroyed. 

Strongylus  paradoxus,  once  found  in  the  dejecta  of  a  man,  is  not 
infrequent  in  the  respiratory  passages  of  the  hog. 

Strongyloides  intestinalis  are  occasionally  found  in  the  stools  in 
the  diarrhea  of  Cochin-China  and  other  hot  countries.  The  worm  was 
formerly  known  as  the  anguillula  stercorahs,  anguillula  intestinalis,  and 
rhabdonema  intestinale. 


DISEASES  CAUSED  BY  THE  CESTODES 


279 


Acanthocephala.— The  echinorhynchus  gigas,  or  gigantorhynchus,  has 
been  found  in  the  intestine.  It  is  not  uncommon  in  the  hog.  Its  inter- 
mediate host  is  the  grub  of  the  cock-chafer,  our  June-bug. 

DISEASES  CAUSED  BY  THE   CESTODES. 

TENIA,   TAPEWORMS,   CYSTICERCI,   HYDATID  CYSTS. 

The  following  general  description  of  the  family  of  Tenioidea  accords 
with  that  of  R.  Hertwig :  Tapeworm  with  scolex  (head)  and  detach- 
able segments  (proglottides) ;  on  the  scolex  four  sucking  disks,  often 
a  rostellum  with  or  without  a  row  of  booklets;  in  the  proglottides  an 
albumin  gland ;  the  uterus  ends  in  a  blind  extremity,  the  porus  genitalis 
or  common  opening  of  the  vas  deferens  and  vagina,  on  one  side  of  the 
segments.  These  rarely  open  separately  on  opposite  sides,  as  in  tenia 
canina.  The  embryonic  stages  are  hydatids  (measles,  cysticerci)  or 
cysticercoidi.  The  tenia  are  hermaphrodites.  If  a  tenia  ovum  enters 
the  intestine  of  man  or  an  animal,  the  embryo  migrates  through 
the  blood-vessels  or  lymph-vessels  into  the  tissues,  and  there  develops 
into  a  hydatid.  The  ovum  of  tenia  solium  produces  a  cysticercus  in 
man  or  the  pig;  that 
of  the  tenia  saginata, 
a  measle  in  the  flesh 
of  cattle.  Ingested 
cysticerci,  on  the  other 
hand,  develop  into  ma- 
ture tenia  in  the  intes- 
tine. The  tenia  and 
cysticercus  require  dif- 
ferent hosts,  except  in  ^  ^  .  ,.  ,  .  ^ 
.,  r  ^1.  1  ■  i*  IG-  21. —  lenia  solium,  showino'  two  segments.  A,  A, 
the  case  of  the    tenia          ^^                                             '^             *=  '     ' 

solium,  both  stages  of 

which  may  occur  in  man.    Infection  may  arise  from  the  ingestion  of 

contaminated  vegetables,  salads,  or  cresses. 

Tenia  Solium  (the  Pork  Tapeworm). — This  form  of  tapeworm  is 
met  with  much  less  frequently  in  this  country  than  in  some  parts  of 
Europe  and  Asia.  The  meat  of  the  hog  is  the  usual  source  of  infection. 
The  mature  worm  is  from  6  to  12  feet  (2 — 3.5  m.)  long.  It  reaches 
maturity  in  from  three  to  three  and  a  half  months,  after  which  the 
segments  begin  to  appear  in  the  stools  of  the  host.  The  head  is  round 
and  smaller  than  the  head  of  a  pin;  it  has  four  sucking  disks  and  is 
armed  with  a  double  row  of  booklets.  Hence  it  receives  the  name  tenia 
armata.  The  neck  is  slender,  almost  threadlike.  The  mature  proglot- 
tides are  about  i  cm.  long  and  6  to  8  mm.  broad.  The  genital  pore 
may  be  on  either  side.  The  uterus  consists  of  a  central  stem  which 
gives  off  at  right  angles  from  five  to  seven  branches  on  each  side  (Fig. 
21).  The  ova  are  round,  brownish,  and  have  a  thick  shell.  When 
the  ova  enter  the  alimentary  canal  of  man,  the  shell  is  digested  and 
the  embryos,  each  of  which  has  six  booklets,  are  liberated.  They  most 
frequently  pass  into  the  liver,  muscles,  brain,  or  eye,  and  there  develop 
into  larvae,  or  cysticerci. 


2  So  PRACTICE  OF  MEDICINE 

Tenia  Saginata. — This  species  is  larger  than  the  tenia  solium.  It 
is  derived  from  beef  and  is  the  form,  almost  exclusively  encountered  in 
this  country.  It  is  often  15  or  20  feet  (4—6  m.)  long.  The  head  is 
larger  than  that  of  the  tenia  solium,  square-shaped,  and  has  four  suck- 
ers, but  no  booklets.  It  is  often  pigmented.  The  segments  are  also 
larger,  and  the  terminal  proglottides  often  measure  an  inch  (2.5  cm.) 
in  length.  The  median  stem  of  the  uterus  resembles  a  central  canal^ 
from  which  resemblance  the  worm  has  been  called  tenia  mediocanellata. 
From  15  to  35  lateral  branches  are  given  off  from  it,  usually  at  an 
acute  angle  (Fig.  22^.  The  ova  are  larger  and  the  shell  thicker  than 
those  of  the  solium.  They  pass  out  of  the  body,  and  when  ingested 
by  cattle  they  develop  into  cysticerci  within  the  flesh.  This  is  probably 
the  universal  source  from  which  man  becomes  infected.  They  have 
been  found  within  the  human  body  in  only  two  or  three  instances. 

Bothriocephalus  Latus  (Tenia  Lata). — This  is  an  extremely  large 
cestode  often  attaining  the  length  of  25  to  30  feet  (9  m.).  The  head 
is  almond-shaped  and  about  2.5  mm.  long.  Instead  of  sucking  disks, 
it  has  two  long,   deep  grooves.     It  is  unarmed.     The  larvse  are  found 

in  the  muscles  of  fish, 
especially  in  the  Baltic 
Sea,  in  parts  of  Switzer- 
land, upper  Italy,  and 
Japan.  It  probably  does* 
not  exist  naturally  in 
our  country,  but  it  is 
met  with  from  time  to 
time  in  Russian  immi- 
grants. 

Tenia  cucumerina  (T. 
elliptica,    dipylidium    ca- 

FlG.  22.— The  uterus  in  a  segment  of  tenia  sagi-  nina)  is  a  small  tape- 
nata.    X3.  worm    often    found     in 

great  numbers  in  the 
dog,  less  frequently  in  the  cat,  occasionally  in  children.  The  flea  and 
louse  harbor  the  larva.  As  many  as  50  cysticerci  have  been  found  in 
a  single  flea. 

Tenia  confusa  is  a  tapeworm  about  16  feet  (5  m.)  long,  two  speci- 
mens of  which  were  secured  by  Ward  at  Lincoln,  Neb.  The  head  is 
small  and  has,  in  addition  to  the  four  suckers,  six  or  seven  rows  of 
hooklets.  The  terminal  segments  are  larger  than  those  of  the  tenia 
saginata. 

Tenia  nana  (T.  Madagascarensis,  Hymenolepsis  nana)  is  the  small- 
est tapeworm  found  in  man.  It  occurs  especially  in  Egypt,  Italy,  Sicily, 
and  Siam. 

Tenia  Diminuta  (T.  Flavopunctata,  Hymenolepsis  Diminuta).— This 
is  a  common  parasite  of  rats  and  mice,  but  is  seldom  found  in  man. 
Its  larva  is  found  in  caterpillars  and  beetles. 

Symptoms  of  Tapeworm.— The  tenia  occurs  in  persons  of  any  age, 
from  early  infancy  to  advanced  senility.  In  many  cases  no  disturbance 
is  produced.  On  the  other  hand,  much  mental  distress,  amounting  to 
hysteria  or  hypochondriasis,  may  be  occasioned  by  the  discovery  of  the 


DISEASES  CAUSED  BY  THE  CESTODES  281 

condition  in  a  person  of  nervous  temperament  or  fastidious  sensibility. 
In  other  respects  much  depends  upon  the  physical  constitution  of  the 
individual.  A  ravenous  appetite  is  sometimes  complained  of,  or  there 
may  be  nausea,  vomiting,  diarrhea,  and  abdominal  pain.  Vertigo,  chorea, 
convulsions,  and  epilepsy  have  been  attributed  to  the  presence  of  the 
worm.  Profound,  even  fatal,  anemia  is  produced  by  the  bothrioceph- 
alus  latus,  and  appreciable  anemia  sometimes  attends  the  other  species. 
In  most  cases,  however,  the  first  indication  of  the  parasite  is  the  dis- 
covery of  the  terminal  proglottides  in  the  stools.  Those  of  the  tenia 
saginata  sometimes  escape  from  the  rectum  and  attract  attention  by 
their  wriggling  movement. 

Diagnosis. — The  passage  of  segments  leaves  no  doubt  as  to  the  diag- 
nosis. The  ova  may  also  be  found  in  the  dejecta.  The  species  of  the 
worm  can  easily  be  determined  by  an  examination  of  the  segments  or 
head. 

Prophylaxis. — The  surest  means  of  prevention  is  the  avoidance  of 
raw  or  insufficiently  cooked  meat  and  unclean  vegetables.  Whenever 
beef  has  a  raw  appearance  and  when  blood  flows  from  the  cut  surface, 
it  should  be  regarded  as  underdone.  Individuals  harboring  tenia  should 
be  careful  not  to  contaminate  water  or  the  soil  with  the  proglottides. 
These  should  in  all  cases  be  burned.  Care  should  be  exercised  also  not 
to  rupture  the  segments  upon  the  person.  The  worm  should  not  be 
handled;  this  is  especially  true  of  the  tenia  solium.  Inspection  of  meat 
is  of  value,  but  inferior  to  thorough  cooking,  as  a  means  of  prophylaxis. 
The  measles  of  beef  are  most  readily  found  in  the  muscles  of  the  jaw; 
those  of  the  hog  in  the  tongue,  muscles  of  mastication,  the  diaphragm, 
neck,  and  shoulder.  The  latter  are  more  easily  recognized  than  those  of 
beef  on  account  of  their  more  opaque,  whitish  color. 

Treatment. — The  treatment  is  the  same  for  all  species;  some  writers 
prefer  one  method,  some  another,  for  each.  The  treatment  consists 
first  in  bringing  the  alimentary  canal  into  a  condition  which  favors 
the  action  of  the  chosen  remedy;  second,  in  the  administration  of  a 
drug  which  is  capable  of  killing  or  benumbing  the  worm;  and  third, 
in  the  administration  of  a  purge  to  remove  it.  The  treatment  should 
be  given  immediately  after  the  discovery  of  the  parasite,  unless  so  large 
a  portion  of  it  has  recently  been  discharged  as  to  render  its  death  prob- 
able. 

Preparatory  Treatment. — For  two  days  the  patient  should  be  placed 
on  a  diet  which  requires  only  stomach  digestion  and  leaves  little  resi- 
due; milk,  soup,  beef,  very  little  bread,  and  no  vegetables  compose  a 
good  diet;  the  exclusive  use  of  milk  is  even  better.  A  mild  laxative 
should  be  given  if  the  bowels  are  sluggish,  or  an  enema  may  be  admin- 
istered the  night  before  the  remedy  is  to  be  taken. 

Medicinal  Treatmettt.—Tht  teniacide  shoulcj  be  administered  in  the 
morning,  fasting,  after  or  with  a  cup  of  coffee,  but  without  food.  The 
male  fern  is  one  of  the  most  effective  remedies.  It  may  be  given  in  the 
form  of  the  ethereal  extract  or  the  oleo-resin  in  dose  of  3  ij  (8.0),  in 
capsules  which  may  be  coated  with  keratin.  Unless  the  remedy  pro- 
duces active  purging,  a  saline  cathartic,  a  half-ounce  of  magnesium 
sulphate,  or  the  citrate  must  be  given.  Castor  oil  should  not  be  used, 
as  it  favors  the  absorption  and  poisonous  effect  of  the  drug. 


2  82  PRACTICE  OF  MEDICINE 

Pomegranate  root  is  an  efficient  remedy.  It  may  be  administered 
in  the  form  of  a  decoction  made  by  boiling  oz.  2  (64.0)  in  i^  pints 
of  distilled  water  down  to  a  pint.  The  entire  quantity  is  given  in  three 
portions  about  a  half-hour  apart.  It  is  objectionable  on  account  of  its 
nauseating  taste.  Vomiting  should  be  avoided,  as  there  is  danger  of 
carrying  the  segments  up  into  the  stomach,  with  a  liability  to  cysticer- 
cus  infection.  The  tannate  of  the  active  principle,  pelleterin,  should 
therefore  be  employed,  since  it  is  tasteless.  It  is  administered  in  the 
dose  of  7  to  10  gr.  (40.0—65.0)  dissolved  in  an  ounce  of  water  which 
may  be  concealed  in  a  glass  of  lemonade.  The  purge  is  given  an  hour 
afterward. 

Pumpkin  seeds  are  often  effective.  Three  or  four  ounces  are  bruised, 
the  outer  rind  being  removed,  and  mascerated  for  twelve  hours.  The 
entire  quantity  is  taken,  and  a  purge  is  given  an  hour  later. 

Among  the  other  remedies  recommended  are  cusso,  kamala,  the  black 
oxid  of  copper,  naphthalin,  and  thymol. 

After  the  worm  has  been  discharged,  it  should  be  carefully  examined 
for  the  head,  remembering  that  this  is  the  smallest  part,  for  unless  this 
has  been  removed,  the  parasite  will  again  attain  full  growth. 

VISCERAL  DISEASES. 

Cysticercus  Cellulosa.— When  the  ripe  ova  of  the  tenia  solium  enter 
the  stomach,  the  embryos  escape  and  soon  burrow  into  the  blood-ves- 
sels and  lymphatics,  whence  they  are  carried  into  the  tissues.  The 
c^ysticercus  is  a  small  vesicle  or  cyst,  not  unlike  a  miniature  bottle. 
Racemose  forms  are  occasionally  seen.  Self-infection  has  repeatedly  oc- 
curred, one  individual  harboring  both  the  tenia  and  the  cysticercus. 

Symptoms. — The  manifestations  depend  upon  the  number  of  cysti- 
cerci  and  their  location.  The  most  frequent  places  of  lodgment  are  the 
muscles  and  subcutaneous  tissue,  the  brain  and  cord,  and  the  eye;  less 
frequently  the  lungs,  liver,  bones,  and  lymph-glands.  When  the  cysti- 
cerci  are  not  numerous,  or  if  they  do  not  affect  a  vital  or  sensitive 
part,  few  or  no  symptoms  are  produced.  In  some  cases,  however,  owing 
to  excessive  involvement  of  the  muscles,  pain,  soreness,  and  stiffness 
are  complained  of  in  the  beginning.  Here  and  elsewhere,  however,  a 
remarkable  tolerance  is  often  begotten. 

Subcutaneous  Cysts.— Thtst  appear  in  the  form  of  one- or  many,  up 
to  1,000,  round  or  oval,  firm,  movable  tumors  of  the  size  of  a  hazel- 
nut. They  are  situated  on  the  trunk  and  extremities,  rarely  on  the 
face.  From  other  small  cutaneous  tumors  they  are  distinguished  chiefly 
by  their  numbers,  tenseness,  and  mobility.  Sebaceous  cysts  are  immov- 
able nodules  in  the  skin;  lypomata  are  larger  and  softer;  gu7mnata  are 
flat,  doughy,   and  tender. 

Cerebrospinal  Cysticerci.—kraoxig  the  most  constant  symptoms  are 
cephalalgia,  epileptiform  or  cumulative  convulsions,  vertigo  and  psy- 
chical disturbances,  with  depression  and  confusion  as  prominent  features. 
Paralyses  are  rare,  since  the  cysts  are  located  in  the  cortex  and  me- 
ninges ;  they  may  develop,  however,  at  a  late  period.  Sudden  death  has 
occurred  in  a  few  instances.  In  the  fourth  and  lateral  ventricles  the 
cysts    sometimes    attain  considerable  size.    When  they  press  upon  the 


ECHINOCOCCUS  DISEASE  283 

floor  of  the  fourth  ventricle,  symptoms  of  diabetes  and  anomalous 
nervous  disturbances  are  produced.  Many  vesicles  may  exist  for  an 
indefinite  time  in  the  silent  region  without  manifestations. 

Ocular  Cysticerci. — The  vesicles  may  occupy  the  anterior  chamber  or 
the  vitreous,  or  they  may  lie  beneath  the  retina  or  conjunctiva.  The 
symptoms  are  those  of  irritation  and  interference  with  vision.  Ophthal- 
moscopic examination  generally  reveals  the  parasite  when  it  is  located 
within  the  chambers. 

Cysticercus  of  the  heart  is  rare  and  is  attended  with  no  symptoms. 
The  same  is  true  of  involvement  of  the  liver  and  lymph-glands.  In 
the  bones  destructive  lesions  are  sometimes  produced. 

The  diagnosis  is  usually  difficult  or  impossible,  except  when  the  cysti- 
cerci are  found  in  the  eye  or  in  the  subcutaneous  tissues,  from  which 
one  can  be  removed  for  examination. 

ECHINOCOCCUS  DISEASE. 

HYDATID   CYST. 

The  Parasite. — The  mature  tenia  echinococcus  is  found  in  the  dog, 
especially  in  mastiff's  and  Newfoundlands;  in  cattle  and  other  animals, 
particularly  sheep.  The  hydatid  echinococcus  is  the  larva,  designated 
the  echinococcus  polymorphus.  The  tenia  is  one  of  the  smallest  cestodes, 
i^^-inch  (4  to  5  mm.)  in  length,  having  but  three  or  four  segments, 
of  which  only  the  terminal  becomes  mature;  it  then  measures  about 
2  mm.  in  length  by  0.6  mm.  in  breadth.  The  head  supports  a  rostel- 
lum  bearing  from  28  to  52  booklets  in  two  rows;  it  has  also  the  usual 
four  sucking  disks.  The  terminal  segment  becomes  filled  with  ova,  esti- 
mated at  5,000,  and  is  then  detached  and  discharged  from  the  alimen- 
tary canal  of  the  host.  Through  the  contamination  of  vegetables  or 
drinking-water,  sometimes  through  direct  contact  with  the  dog,  it  reaches 
the  human  intestine.  Here  the  embryo,  which  is  armed  with  six  hook- 
lets,  is  set  free  and  at  once  bores  through  the  intestine-wall  until  it 
reaches  the  lymphatics  or  blood-vessels.  When  it  reaches  the  portal 
vein  it  is  carried  to  the  liver,  one  of  its  most  frequent  lodging-places. 
When  it  enters  the  general  circulation,  it  is  carried  to  the  lungs,  or,  pass- 
ing on,  may  reach  the  brain,  spleen,  kidneys,  muscles,  or  other  parts. 

The  Hydatid  C/sf.— After  reaching  its  destination,  the  embryo  loses 
its  six  booklets  and  acquires  a  vesicular  form,  through  the  growth 
from  its  caudal  extremity  of  a  serous  membrane  which  ultimately  envel- 
ops it  and  becomes  distended  with  a  clear  fluid.  It  thus  becomes  the 
echinococcus  cyst.  Its  growth  is  slow;  years  sometimes  elapse  before 
it  becomes  large  enough  to  produce  appreciable  disturbance.  As  usually 
found,  the  size  varies  from  that  of  a  pea  to  that  of  the  human  head, 
rarely  larger.  The  cyst  consists  of  a  delicate  substance,  chitin,  and 
is  separable  into  two  layers.  The  outer  of  these  is  laminated ;  the  inner, 
known  as  the  parenchymatous  or  germinal  layer,  is  granular.  The 
presence  of  the  cyst  occasions  a  reaction  on  the  part  of  the  tissues 
which  results  in  the  formation  of  a  firm  fibrous  wall  about  it.  After  a 
variable  time,  usually  from  two  to  five  months,  little  mounds  appear 
upon  the  surface  of  the  germinal  layer,  each  having  at  its  apex  a  small 


2S4  PRACTICE  OF  MEDICINE 

depression  which  later  becomes  a  cavity.  These  cavities  enlarge  and 
become  secondary  or  daughter-cysts.  This  process  of  budding  may 
take  place  also  in  the  daughter-cysts  and  give  rise  to  granddaughter- 
cysts.  Either  generation  may  develop  either  endogenously  or  exoge- 
nously.  The  former  is  the  more  common  method  of  growth  in  man. 
The  number  of  cysts  formed  varies  from  a  few  to  several  thousand. 
From  the  germinal  surface  of  the  daughter-cysts,  sometimes  from  the 
mother-cyst,  scolices,  the  heads  of  embryonic  teniad,  evelop.  These 
appear  as  conical  projections,  each  having  on  its  free  extremity  a  ros- 
tellum  armed  with  a  double  row  of  booklets  and  four  suckers.  The 
other  extremity  becomes  constricted  into  a  narrow  pedicle,  which  later 
divides,  liberating  the  scolex,  thenceforth  to  float  freely  about  in  the 
interior  of  the  capsule.  Each  of  these  scolices,  from  one  to  nine  or 
more  in  each  capsule,  is  capable  of  development  into  a  mature  tape- 
worm within  the  intestine  of  the  dog.  It  occasionally  happens  that 
daughter-cysts  are  formed  within  the  scolex.  In  another  variety  of 
cyst  the  daughter-cysts  are  sterile;  they  are  then  known  as  acephalo- 
cysts. 

The  Multilocular  Echinococcus. — This  form  of  cyst  is  encountered  once 
in  about  i8o  cases  of  the  disease.  The  sac,  sometimes  of  very  large 
size,  is  surrounded  by  an  exceedingly  dense  fibrous  capsule  firmly  united 
to  the  surrounding  tissue.  It  is  subdivided  into  numerous  small  cavities 
and  is  filled  with  a  thick,  gelatinous,  or  colloid  material  suggestive  of 
cancer.  It  is  probably  not  due  to  the  tenia  echinococcus,  but  a  form  of 
the  echinococcus  in  which  there  is  no  intermediate  host.  Recent  investi- 
gation has  shown  that  after  the  embryo  has  reached  the  liver  by  the 
same  route  as  the  other  parasite  pursues,  a  multilocular  chitinous  struc- 
ture is  formed  which  resembles  the  mature  proglottis  of  a  tapeworm. 
From  the  granular  protoplasm  which  lines  the  cyst-wall  within  and 
without,  there  are  formed  not  only  scolices,  but  young  parasites  and 
ovoid  embryos.  If  these  embryos  gain  access  to  the  blood-vessels  or 
bronchioles  they  may  develop  new  cysts.  The  new  cysts  remain  sterile. 
Metastasis  may  also  occur,  the  embryos  being  carried  to  the  lymph- 
glands,  lung,  brain,  or  elsewhere. 

The  fluid  of  the  echinococcus  cyst  is  limpid,  usually  clear,  of  neutral 
reaction,  and  has  a  specific  gravity  of  from  1.006  to  1.015.  Sometimes, 
however,  it  has  a  pale  green  tint  and  is  slightly  alkaline  from  admix- 
ture of  bile,  opalescent  from  the  presence  of  fatty  matter  or  other  debris; 
or  pale  red  blood  is  present  in  it.  Chemical  analysis  shows  the  presence 
of  from  0.50  to  0.75  per  cent  of  sodium  chlorid  and  small  quantities 
of  the  earthy  compounds  of  succinic  acid,  inosit,  and  grape-sugar.  Albu- 
min is  not  normally  present.  Urea,  creatin,  hematoidin,  and  substances 
resembhng  toxalbumins  and  ptomains  have  been  found  in  it.  Micro- 
scopic examination  of  it  usually  reveals  scolices,  booklets,  and  occasion- 
ally fragments  of  the  chitinous  membrane. 

The  echinococcus  sometimes  dies,  spontaneously  or  as  a  result  of 
some  accident.  Its  growth  is  then  arrested  and  its  contents  undergo 
retrograde  changes  converting  them  into  a  pasty  mass  which  may 
later  undergo  calcification,  or  it  may  be  partially  absorbed.  Suppu- 
ration sometimes  occurs  and  the  rupture  of  the  abscess  may  lead  to 
serious  consequences. 


ECHINOCOCCUS    DISEASE  285 

£//o/o^/.— Echinococcus  disease  is  met  with  most  frequently  in  Ice- 
land, where  the  people  live  in  intimate  association  with  their  dogs,  and 
among  the  shepherds  of  Australia.  No  part  of  the  world  is  exempt, 
but  the  disease  is  rare  in  the  United  States.  Lyon  was  able  to  collect 
only  241  cases  in  America  up  to  July,  igoi.  The  disease  affects  the 
sexes  alike  and  at  all  ages  after  infancy.  Except  in  Iceland,  perhaps, 
the  disease  is  most  frequently  contracted  through  eating  infested  meat. 
Scolex-bearing  cysts  have  been  found  in  the  flesh  of  the  ox,  sheep,  hog, 
goat,  deer,  horse,  and  squirrel.  Autoinfection  is  possible,  although  the 
tenia  has  seldom  been  known  to  enter  the  human  intestine. 

Symptoms. — Echinococci  frequently  exist  for  years  without  occasion- 
ing symptoms.  The  greater  number  have  been  found  at  autopsy.  In 
most  instances  the  first  symptom  to  attract  attention  is  the  formation 
of  a  tumor ;  the  direction  of  greatest  protrusion  depends  upon  its  loca- 
tion. In  fully  half  the  cases  the  hydatid  is  located  in  the  liver,  next 
most  frequently  in  the  lung  or  pleura,  then  in  the  kidney,  bladder  or 
genitals,  brain,  spinal  canal,  bone,  heart,  blood-vessels,  or  other  organs. 
Hydatid  of  the  Liver.— T\\t  first  indication  is  generally  that  of  en- 
largement of  the  organ  or  the  protrusion  of  a  tumor  into  the  hypo- 
gastrium  or  upward  into  the  thorax,  corresponding  to  the  location 
of  the  cyst.  A  large  tumor  pushing  upward  impedes  respiration  and 
sometimes  displaces  the  heart  to  the  left.  Pushing  downward,  it  may 
extend  to  the  pelvis.    When  in  the  left  lobe  it  may  displace  the  spleen. 

If  accessible  to  palpation,  the  cyst  gives  the  impression  of  a  smooth, 
globular  tumor,  sometimes  fluctuating,  usually  irregular  in  outline.  If 
it  be  of  large  size  and  contain  many  daughter-vesicles  and  the  abdomi- 
nal wall  be  thin,  we  may,  by  grasping  the  tumor  and  exerting  moderate 
compression  with  one  hand  and  striking  a  quick,  rather  forcible  blow 
upon  it  with  the  other,  elicit  a  peculiar  vibratory  sensation  which  has 
been  compared  to  the  trembling  of  a  bowlful  of  jelly,  and  known  as 
the  hydatid  purring  of  Brian9on.  The  sign  is  absent  in  about  half  the 
cases,  and  is  not  always  trustworthy.  Many  cases  are  attended  with 
pressing,  undefined,  or  sharp  pain.  Pressure  symptoms  attend  all  large 
cysts.  Prominent  among  these  are  dyspnea,  cough,  cardiac  palpita- 
tion, indigestion,  vomiting,  constipation,  and  later  ascites  and  occa- 
sionally varicose  veins.  Jaundice  is  not  often  present,  unless  late  in 
the  disease.  There  is  usually  no  fever  unless  suppuration  has  occurred, 
and  the  nutrition  of  the  patient  is  generally  maintained. 

Rupture  of  the  cyst  occasions  a  new  train  of  symptoms,  varied  with 
the  direction  in  which  it  occurs.  Spontaneous  recovery  has  followed 
rupture  through  the  external  abdominal  wall,  or  into  the  intestine,  bile- 
duct,  ureter,  or  vagina,  but  rupture  into  the  pericardium  or  inferior 
vena  cava  is  necessarily  fatal.  The  accident  is  usually  attended  with 
sudden,  sharp  pain  and  a  variable  degree  of  shock.  Urticaria  appears 
on  the  skin  after  rupture  internally. 

The  midtilocular  echinococcus  is  generally  firm,  seldom  fluctuates,  and 
is  often  sensitive.  It  is  commonly  accompanied  with  enlargement  of  the 
spleen  and  ascites.  Gastric  and  intestinal  disturbance,  hemorrhage,  and 
jaundice  are  also  more  frequent  in  connection  with  it. 

Diagnosis. — The  disease  is  to  be  differentiated  from  cancer,  amyloid 
disease,  syphilis,  cirrhosis,  and  abscess  of  the  liver  and  occasionally  from 


286  PRACTICE  OF  MEDICINE 

hydrothorax,  pyothorax,  cystic  disease  of  the  retroperitoneal  glands, 
ovarian  cyst,  enlargement  of  the  gall-bladder,  and  aneurism  of  the  aorta. 
In  its  early  history  the  dififerentiation  may  be  quite  difficult.  A  tumor 
of  slow  growth,  elastic,  fluctuating,  and  giving  the  hydatid  fremitus  is 
generally  an  echinococcus.  The  diagnosis  is  established  if  the  fluid 
withdrawn  through  a  small  aspirator  needle  is  found  to  be  character- 
istic. 

Cancer  is  more  painful,  grows  more  rapidly,  is  firmer,  and  produces 
greater  emaciation  and  cachexia. 

The  amyloid  liver  is  hard,  the  edge  sharp  and  smooth;  the  skin  is 
waxy,  and  there  is  a  history  of  suppuration  or  syphilis. 

Syphilis  must  be  excluded  by  the  history  and  evidences  of  previous 
lesions. 

Cirrhosis  reduces  the  size  of  the  liver,  roughens  its  surface,  and  fol- 
lows chronic  alcoholism.     The  ascites  is  usually  greater. 

Hepatic  abscess  is  attended  with  fever  and  other  evidences  of  sepsis. 
The  needle  withdraws  pus;  but  suppuration  may  occur  in  the  hydatid 
cyst.     The  differentiation  is  then  not  important. 

Hydrothorax  and  pyothorax  are  recognized  by  tbe  level  line  of  dull- 
ness, changing  with  a  change  of  position.  In  echinococcus  the  highest 
margin  is  usually  in  the  axillary  line. 

Cystic  enlargement  of  the  retroperitoneal  lymph-glands  is  rare  and  may 
not  be  excluded  without  exploratory  incision. 

Distention  of  the  gall-bladder  is  recognized  by  the  character  of  the  fluid 
withdrawn. 

Aortic  aneurism  is  recognized  by  its  location  as  well  as  by  pulsation 
and  thrill.     Pulsation  may  be  transmitted,  however,  to  a  hydatid  cyst. 

Echinococcus  of  the  Lung  and  Pleura.— The  cysts  may  exist  for  a 
long  time  in  the  lungs  without  occasioning  symptoms.  Later  they 
lead  to  inflammation,  occasionally  to  gangrene  with  the  production  of 
cavities.  When  communication  has  been  established  with  a  bronchus, 
small  cysts  or  fragments  of  membrane  and  booklets  may  be  found 
in  the  expectoration.  Hemorrhage  is  not  infrequent,  and  rupture  into 
the  pleural  cavity  may  occur.     The  diagnosis  is  rarely  made  during  life. 

When  the  cysts  are  in  the  pleura,  the  symptoms  are  those  of  hydro- 
thorax ;  but  the  outline  of  dullness  is  often  irregular  and  does  not  change 
when  the  patient  lies  down.  Spontaneous  evacuation  may  take  place 
through  the  chest-wall. 

Echinococcus  of  the  Kidneys.— Few  symptoms  are  observed  in  many 
cases  until  the  cyst  ruptures.  The  small  cysts  cause  pain  in  their  pas- 
sage, and  their  presence  in  the  urine  is  diagnostic  of  the  disease.  With- 
out rupture,  the  character  of  the  condition  can  be  determined  only  by 
examination  of  the  fluid  obtained  through  aspiration. 

Echinococcus  of  the  brain  is  fortunately  a  rare  affection.  The  symp- 
toms are  those  of  brain  tumor  and  depend  largely  upon  location.  The 
character  of  the  tumor  can  rarely  be  determined  during  life. 

Prognosis.— This  depends  upon  the  size  and  location  of  the  cyst. 
Unless  terminated  by  the  death  of  the  echinococcus  or  by  operation, 
the  disease  is  ultimately  fatal. 

The  prophylaxis  is  the  same  as  that  of  the  other  diseases  caused  by 
the  cestodes. 


PARASITIC  INSECTS  287 

Treatment.— The  treatment  is  purely  surgical.  The  withdrawal  of  a 
small  quantity  of  fluid  under  aseptic  precautions  may  result  in  the  death 
of  the  parasite,  but  incision  is  generally  necessary.  This  should  not  be 
delayed.     The  method  is  detailed  in  the  textbooks  on  surgery. 

PARASITIC  ARACHNIDS. 

1.  Linguatilina. — (^)  Lmguatula  rhinaria  (Pentastoma  tenioides)  is 
a  lancet-shaped  arachnid,  the  male  about  i  inch  (2.5  cm.),  the  female 
3  inches  (7.5  cm.)  in  length,  with  a  tapering  body  marked  by  numerous 
rings.  It  infests  the  nostrils  and  frontal  sinus  of  the  dog,  sometimes 
those  of  the  horse,  rarely  attacking  man.  The  larva,  known  as  the 
linguatula  serrata  or  pentastomum  denticulatum,  invades  the  internal 
organs,  especially  the  liver  of  animals,  sometimes  also  of  man. 

(Z")  Porocephalus  constrictus  (Pentastomum  constrictum)  is  rare 
in  this  country.  It  is  about  %  inch  (12.5  mm.)  in  length  and  is  found 
in  the  liver  and  lungs. 

2.  Sarcoptes. — The  most  important  of  this  class  is  the  acarus  scabei, 
or  itch  mite,  the  cause  of  the  disease  commonly  called  the  itch.  The 
male  measures  0.23  x  0.19  mm.  and  the  female  is  almost  twice  as  large. 
It  is  much  more  common  in  Europe  than  in  America.  It  lives  in  bur- 
rows beneath  the  epidermis,  but  the  male  is  seldom  found.  The  itch 
mite  is  readily  destroyed  by  giving  the  affected  region  a  thorough  scrub- 
bing with  good  soap,  twice  daily,  then  applying  a  mild  sulphur  ointment. 

3.  Demodex  (Acarus)  Folliculorum.— This  parasite,  known  also  as 
the  comedo  mite,  is  about  0.4  mm.  in  length  and  occasionally  occupies 
the  sebaceous  follicles,  especially  those  of  the  face,  and  may  produce 
acne. 

4.  Another  form  of  acarus,  normally  a  parasite  of  plants,  produces 
the  adobe  itch  of  tropical  countries. 

5.  Leptus  autumnalis,  or  harvest  bug,  occasionally  becomes  para- 
sitic by  attaching  itself  to  the  skin  of  the  legs.  Much  irritation  may 
be  produced  by  its  sharp  proboscis  and  the  booklets  of  its  legs.  It 
is  destroyed  by  mercurial  or  sulphur  ointment. 

6.  Ixodes. — Several  species  of  the  tick  occasionally  become  parasitic 
to  man,  notably  the  Ixodes  albipictus,  ricinis,  and  bovis,  also  known 
as  Dermacantor  Americanus.  Some  species  are  also  regarded  as  car- 
riers of  bacteria. 

LARGER  PARASITIC  INSECTS. 

I.  Pediculosis. — Pediculi,  or  lice,  are  of  three  species,  each  of  which 
inhabits  different  regions  of  the  body.  The  condition  is  known  as  pedic- 
ulosis or  phthiriasis. 

(<z)  Pediculus  capitis,  an  insect  of  grayish,  white,  or  brownish  color, 
with  six  legs  under  the  fron.t  part  of  the  body.  The  male  is  about  i 
to  1.5  mm.  long;  the  oviparous  female,  about  twice  as  large,  produces 
about  80  eggs  in  a  week.  These  ''nits"  can  be  seen  attached  to  the 
sides  of  the  hairs.  Their  presence  is  indicated  by  the  itching  of  the  head. 
Dermatitis  and  eczema  are  sometimes  produced;  large  crusts  are  often 
formed  in  filthy  persons.  The  plica  polonica,  occasionally  seen  on  the 
heads  of  recent  immigrants  from  Poland,  is  of  this  character. 


288  PRACTICE  OF  MEDICINE 

Qb^  Fedicidus  vestamejitorum  (P.  corporis),  the  large  body  louse  or 
gray-back,  the  companion  of  the  hobo.  It  inhabits  the  clothing,  and 
invades  the  body  only  for  the  purpose  of  drawing  blood.  As  a  result 
of  the  itching  produced  by  its  bites,  the  skin  of  the  individual  is  usually 
streaked  with  the  recent  or  old  pigmented  marks  caused  by  scratching, 
especially  in  those  regions  where  the  clothing  fits  closely  to  the  body. 

((t)  Phthirius  Pubis. — The  crab-louse  is  an  ovoid  insect  which  in- 
habits particularly  the  hair  of  the  pubic  region,  but  occasionally  invades 
that  of  the  breast,  axillae,  beard,  and  eyebrows. 

Treatment. — (i)  The  pediculus  capitis  can  be  quickly  removed  by 
saturating  the  hair  with  coal-oil  or  turpentine,  scrubbing  with  a  soft 
soap,  then  saturating  it  with  vinegar,  and  finally  rinsing  with  clear 
water.  The  oil  destroys  the  pediculus,  the  vinegar  ruptures  the  ova. 
One  or  two  treatments  usually  suffice.  (2)  The  pediculus  vestamen- 
torum  requires  thorough  cleansing  of  the  body  and  disinfection  of  the 
clothing  in  a  disinfecting-oven  for  several  hours.  The  itching  is  re- 
lieved by  a  lotion  containing  sodium  bicarbonate  and  carbolic  acid 
(2  per  cent)  applied  after  the  bath,  or  by  the  application  of  carbolated 
vaselin.  (3)  For  the  crab-louse,  thorough  bathing  and  the  application 
of  the  blue  mercurial  ointment  or  an  ointment  of  the  white  precipitate 
is  curative. 

2.  Cimex  lectularius  (bedbug),  a  small,  fiat,  nearly  round,  reddish 
brown  insect  3  to  4  mm.  in  length,  may  be  recognized  by  its  peculiarly 
offensive  odor,  due  to  the  secretion  of  a  gland.  Its  bite  is  exceedingly 
poisonous  to  some  persons,  causing  intense  hyperemia  or  urticaria. 

3.  Pulex  Irritans  (the  Common  Flea). — The  flea  is  a  small,  nearly 
black  insect,  the  male  from  2  to  2.5  mm.  and  the  female  from  3  to  4 
mm.  in  length.  The  bite  produces  circular,  bright  red  spots.  In  some 
individuals  a  marked  hyperemia  or  urticaria  is  produced.  Tolerance 
seems  to  be  acquired  by  those  living  in  localities  where  fleas  abound. 

4.  Pulex  penetrans  (sand-flea  or  jigger)  is  a  common  parasite  of 
tropical  countries,  especially  the  West  Indies  and  South  America.  It 
attacks  especially  the  feet  and  ankles,  penetrates  the  skin  and  produces 
burrows  which  frequently  suppurate,  causing  pustules  and  often  enlarge- 
ment of  the  lymph-glands.  Its  removal  is  not  difficult.  Application 
of  an  essential  oil  to  the  feet  prevents  its  invasion. 

Other  parasites  are  the  Dermonyssus  avium  and  gallinae,  bird  and 
chicken  lice;  culicidae,  mosquitoes  and  gnats;  estridte,  bot-flies;  and 
muscidae,  common  house-flies.  Bees,  wasps,  ants,  and"  spiders  some- 
times act  as  parasites  and  by  their  bites  or  stings  cause  great  and 
painful  swelling,  sometimes  with  toxic  effects.  Caterpillars  occasionally 
cause  urticaria,  apparently  by  the  irritation  of  their  bristles.  The  sev- 
eral species  of  flies  named,  and  many  others  peculiar  to  certain  regions, 
especially  the  tropics,  are  not  only  annoying  by  their  bites,  but  their 
larvae  occasionall}'  infest  wounds  or  sinuses,  and  sometimes  gain  en- 
trance to  the  ears  or  nostrils,  or  to  the  vagina  after  parturition.  The 
condition  is  known  as  myiasis. 


SECTION    III. 
Diseases  of  the  Blood  and  Ductless  Glands. 


DISEASES    OF   THE    BLOOD. 


POLYCYTHEMIA. 

The  term  polycythemia  is  applied  to  a  relative  increase  of  the  number 

of  the  red  blood-corpuscles,  whether  this  be  due  in  reality  to  an  actual 
numerical  increase,  or  to  a  decrease  in  the  volume  of  the  plasma.  It  is  a 
normal  condition  of  the  blood  in  the  newborn  before  nursing  begins,  the 
red  cells  often  reaching  6,000,000  in  the  cubic  millimeter.  An  increase  of 
a  million  or  more  corpuscles  rapidly  ensues  upon  assuming  residence  in 
a  high  altitude,  and  it  is  believed  to  become  a  permanent  condition 
until  the  individual  returns  to  a  lower  altitude. 

Polycythemia  occurs  also  in  cholera  and  other  diarrheal  diseases, 
sometimes  in  typhoid  fever.  Relative  increase  of  the  red  corpuscles  may 
be  found  in  chronic  valvular  disease  of  the  heart,  with  passive  hyperemia, 
in  endocarditis,  after  excessive  sweating,  poisoning  by  illuminating  gas 
or  phosphorus,  and  after  cold  baths  or  the  application  of  alcohol  and 
other  drugs  that  cause  contraction  of  the  blood-vessels. 

Polycythemia  with  Chronic  Cyanosis. — This  condition,  as  a  clinical 
entity,  was  first  brought  prominently  before  the  profession  by  Osier,  in 
May  and  August,  1903,  although  it  had  been  described  a  year  before  by 
Saundby  and  Russell,  of  England.  The  condition  is  one  of  general 
cyanosis,  in  which  the  only  pathological  lesion,  in  addition  to  slight  en- 
largement of  the  spleen,  is  a  polycythemia.  The  red  corpuscles  range 
from  7,000,000  to  12,000,000  in  the  cubic  millimeter.  The  hemoglobin 
is  correspondingly  increased;  the  leucocytes  are  normal.  Congenital 
heart  lesions,  emphysema,  and  other  causes  of  cyanosis  were  carefully 
excluded,  and  there  was  no  dyspnea  in  the  cases  observed  by  Osier.  A 
trace  of  albumin  was  found  in  the  urine,  but  not  sufficient  to  indicate 
disease  of  the  kidneys.  Weakness,  prostration,  constipation,  headache, 
and  vertigo  were  the  prominent  symptoms.  The  blood  was  black  and 
flowed  sluggishly  from  the  ear  puncture.  Similar  cases  were  reported  by 
Cabot,  Shattuck,  Stockton,  and  others. 

ANEMLA.. 

Definition. — A  reduction  of  the  quantity  of  the  blood  as  a  whole 
or  of  one  or  more  of  its  cellular  or  chemical  constituents.  The  greatest 
reduction  affects  the  red  corpuscles.  These  may  be  greatly  diminished 
in  number,  or  their  hemoglobin  alone  may  be  deficient.  Anemia  may 
be  local  or  general.    Local  anemia  is  considered  on  page  11. 

19 


2go  PRACTICE  OF  MEDICINE 

General  anemia  may  be  primary  or  secondary  in  origin,  (i)  J^ri- 
mary,  essential,  or  cytogenic  anemia  arises  as  an  independent  disease. 
It  embraces  the  two  affections,  pernicious  anemia  and  chlorosis.  (2) 
Secondary  anemia  results  from  such  causes  as  hemorrhage,  inanition, 
infectious  toxemia,  metallic  or  gaseous  poisons,  and  autointoxications. 

I.    PRIMARY  ANEMI.\. 

Pernicious  Anemia  (Idiopathic,  or  Progressive,  Pernicious  Anemia). — 
A  fatal  form  of  anemia,  probably  of  infectious  origin,  showing  an  extreme 
reduction  of  the  number  of  red  blood-corpuscles,  preponderance  of  mega- 
loblasts,  and  other  changes  in  the  cellular  elements,  and  various  result- 
ant changes  in  the  organs  and  tissues  generally. 

Etiology. — The  disease  may  affect  either  sex  at  any  age,  but  middle- 
aged  men  are  oftener  attacked  than  women  or  children.  The  disease 
is  more  common  in  European  countries  than  in  our  own,  and  especially 
in  England  and  Switzerland.  It  sometimes  develops  during  pregnancy 
or  soon  after  its  termination.  A  clear  distinction  has  not  always  been 
made  between  the  pure  pernicious  anemia,  first  described  by  Addison, 
and  severe  forms  of  secondary  anemia  due  to  the  presence  of  intestinal 
parasites,  as  the  bothriocephalus  latus  and  the  ankylostoma.  Atrophy 
of  the  stomach  has  been  repeatedly  observed  after  death,  and  it  has 
been  regarded  as  a  cause  in  some  instances.  In  nearly  all  cases  there 
is  a  history  of  more  or  less  prolonged  disturbance  of  gastric  or  intesti- 
nal digestion,  preceding  the  recognition  of  the  anemia,  but  the  lesions 
have  not  usually  been  so  severe  as  to  be  regarded  as  the  sole  cause  of 
the  blood-changes.    What  the  exciting  cause  is,  we  do  not  know. 

Theory  of  Infection. — Many  attempts  have  been  made  to  discover 
a  bacterial  origin,  but  without  definite  success.  A  new  impetus  has 
been  given  to  the  search  by  the  investigations  of  Hunter,  who  has 
found  as  constant  features  a  special  type  of  glossitis  and  septic  lesions 
in  the  mouth,  stomach,  or  intestines  separately  or  in  combinations. 
Various  bacteria  have  been  found,  but  no  single  organism  has  been 
identified  with  the  disease,  and  it  is  highly  probable  that,  if  any,  more 
than  one  species  may  be  capable  of  producing  infection.  The  site  of 
initial  inoculation  is  probably  the  tongue,  but,  perhaps,  in  some  cases 
another  part  of  the  gastrointestinal  tract.  The  infection  is  evidently 
a  chronic  one;  and  an  important  feature  in  its  pathology,  if  not  in  its 
etiology,  as  believed  by  Quincke  and  others,  is  the  peculiar  type  of  hem- 
olysis manifested  in  the  excess  of  iron  in  the  liver,  spleen,  and  kidneys. 

Morbid  Anaiomy. — The  surface  of  the  body  is  extremely  pale  and 
often  has  a  distinct  lemon  hue,  but  emaciation  is  unusual.  The  muscles 
are  red;  most  of  the  other  tissues  are  pale  and  anemic.  All  the  organs 
show  fatty  degeneration.  The  heart  is  large,  soft,  and  fatty.  The 
ventricles  are  usually  empty  or  contain  a  little  light-colored  blood. 
Ecchymoses  are  generally  found  in  the  skin  and  mucous  membranes, 
and  small  extravasations  in  the  various  other  organs  and  tissues  of  the 
body.  The  serous  cavities  may  contain  an  increased  quantity  of  serum, 
and  moderate  general  or  localized  edema  is  common.  The  liver  and 
spleen  may  be  normal  in  size  or  slightly  enlarged,  but  both  these  organs 
and  the  kidneys  contain  a  large  quantity  of  iron  derived  from  the  blood. 


ANEMIA  291 

In  the  liver  the  deposit  is  confined  to  the  outer  and  middle  zones  of 
the  lobules. 

Hunter  records  a  peculiar  type  of  glossitis  found  in  25  consecutive 
cases,  and  in  seven  of  the  cases  examined  post  mortem  septic  gastritis 
with  more  or  less  atrophy  of  the  stomach,  and  in  three  of  the  cases  a 
septic,  croupous  enteritis,  patches  of  congestion,  enlargement  of  the  fol- 
licles, and  localized  areas  of  colitis. 

The  blood-changes  are  typical  of  the  disease.  During  the  earlier 
stage,  blood  obtained  from  the  finger  or  ear  is  fairly  normal  in  color. 
The  color  index  is  higher  than  in  any  other  form  of  anemia,  owing 
to  a  relatively  large  quantity  of  hemoglobin  contained  in  the  corpuscles. 
This  ratio  may,  in  fact,  be  normal  or  increased.  The  red  cells  are  al- 
ways greatly  reduced,  the  average  number  to  the  cubic  millimeter  being 
1,000,000,  but  in  extreme  cases  there  may  be  only  200,000  or  400,000. 
The  most  distinctive  feature  of  the  blood-count,  however,  is  the  great 
abundance  of  megaloblasts.  Normoblasts  may  be  so  few  as  to  be  de- 
monstrable with  difficulty;  they  are  never  so  numerous  as  the  megalo- 
blasts. Eichhorst's  corpuscles  (small  red  cells  without  indentation) 
are  usually  seen.  The  leucocytes  are  reduced  in  number,  but  there  is 
a  relative  increase  of  large  and  small  mononuclears.  Poikilocytosis, 
or  irregularity  of  form,  is  often  extreme.  Hyperleucocytosis  may  be 
encountered.  The  erythrocytes  are  somewhat  larger  than  norm.al,  and 
megalocytes  may  be  numerous.  Oval  erythrocytes  are  not  unusual. 
Degeneration  of  the  sympathetic  ganglia  has  been  repeatedly  observed, 
and  posterior  spinal  sclerosis  in  a  few  cases. 

Sympfoms. — There  is  in  most  cases  a  history  of  repeated  gastro- 
intestinal disturbance,  occasional  attacks  of  vomiting,  constipation, 
or  irregular  diarrhea,  possibly  with  blood  in  the  stools,  and  these  symp- 
toms sometimes  persist  throughout  the  course  of  the  disease.  But  the 
symptoms  are  not  always  so  severe  as  to  occasion  pronounced  illness. 
The  beginning  is  generally  so  insidious  as  not  to  be  recognized  by  the 
patient  until  languor  and  muscular  weakness,  with  increasing  faintness 
and  breathlessness  after  slight  exertion,  pallor  and  waxiness  of  the 
face,  call  attention  to  it.  The  mucous  membranes,  expecially  those  of 
the  eyelids,  lips,  tongue,  and  gums,  become  blanched;  the  muscles  are 
flabby  and  the  heart  is  thrown  into  palpitation  by  exertion  or  a  ner- 
vous shock.  Hemic  murmurs  usually  develop;  the  pulse  is  full  and  some- 
times of  the  water-hammer  type;  the  throbbing  of  the  arteries  is  often 
visible  and  may  be  felt  by  the  patient.  The  appetite  is  lost;  headache, 
vertigo,  and  restlessness  become  more  and  more  constant.  Retinal  hemor- 
rhage, with  consequent  amaurosis,  sometimes  occurs.  The  skin  becomes 
yellow,  ecchymoses  appear,  possibly  slight  edema  of  the  ankles,  and 
finally,  from  extreme  weakness,  the  patient  becomes  unable  to  leave  his 
bed.  The  course  of  the  disease  is  irregular  and  to  some  extent  inter- 
mittent, intervals  of  apparent  improvement  separating  periods  of  de- 
cline. Slight  fever  may  be  observed  in  the  evening,  but  the  temperature 
may  become  subnormal  toward  the  end.  Many  patients  suff'er  from 
hemorrhages  of  the  nose,  gums,  intestines,  or  kidneys.  Various  nervous 
manifestations  supervene  in  about  a  third  of  the  cases,  including  anes- 
thesia, spinal  paralysis,  aphasia,  or  tetany.  The  long  bones  often  be- 
come sensitive  to  pressure.    The  urine  is  pale  and  of  low  specific  gravity. 


292  PRACTICE  OF  MEDICINE 

except  when  it  contains  much  urobihn.    Albuminuria  is  rare,  peptonuria 
comparatively  common. 

Diagnosis. — This  form  of  anemia  is  distinguished  from  chlorosis  and 
other  forms  chiefly  by  the  extreme  decrease  of  red  blood-corpuscles 
and  relative  increase  of  hemoglobin,  with  preponderance  of  megalo- 
blasts.  The  constant  presence  of  glossitis,  if  confirmed,  will  prove  a 
valuable  aid  to  diagnosis.  The  greatest  difificulty,  as  a  rule,  lies  in  the 
exclusion  of  gastric  cancer  with  extreme  anemia,  but  the  blood-count 
of  cancer  rarely  approaches  that  of  primary  anemia,  and  the  emaciation 
is  rapid  and  extreme.  The  chemical  examination  of  the  stomach  con- 
tents may  further  establish  the  diagnosis. 

Prognosis. — The  prognosis  of  a  pure  pernicious  anemia  is  very  un- 
favorable, but  more  or  less  complete  recovery  has  been  repeatedly  ob- 
served, sometimes  lasting  indefinitely,  sometimes  followed  by  relapses. 
Extreme  lowness  of  the  red  blood-corpuscles  and  the  presence  of  great 
numbers  of  megaloblasts  are  regarded  as  of  bad  prognosis,  but  the 
blood-count  is  too  changeable  to  constitute  a  reliable  guide. 

Treatment. — Arsenic  has  proved  the  most  valuable  remedy.  Its  action 
sometimes  appears  almost  specific.  It  is  best  given  in  the  form  of  Fow- 
ler's solution,  beginning  withTTl,  iij  (0.18)  t.  i.  d.,  and  increasing  one  minim 
each  day  until  Tll.xx  to  xxv  (1.2  to  1.5)  are  given,  unless  toxic  symptoms 
arise.  The  remedy  should  then  be  discontinued  for  a  few  days  and 
resumed  in  reduced  dose.  Iron  is  seldom  useful,  but  it  may  be  tried 
when  arsenic  fails  after  proper  trial.  Outdoor  life,  with  light  exercise, 
abundant  rest,  and  nutritious  food,  is  an  important  adjunct  to  the  treat- 
ment. 

Hunter  and  his  followers  have  observed  good  results  from  the  admin- 
istration of  intestinal  antiseptics  and  the  injection  of  antistreptococcus 
serum.  Inhalations  of  oxygen  prove  beneficial  in  some  cases,  but  useless 
in  others,  and  this  is  true  of  many  other  remedies. 

Chlorosis  (Green  Sickness). — A  primary  anemia  occurring  chiefly  in 
young  girls  and  characterized  by  a  great  deficiency  in  the  quantity  of 
hemoglobin,  and  less  marked  reduction  of  the  number  of  red  corpuscles, 
with  pallor  and  other  evidences  of  the  condition. 

Chloranemia  signifies  an  anemic  condition  of  the  blood,  like  that  of 
chlorosis,  often  observed  as  a  result  of  tuberculosis,  syphilis,  cancer,  and 
other  affections,  and  not  infrequently  in  persons  whose  age  and  sex  do 
not  correspond  to  the  definition  given. 

Etiology. — Girls  of  blond  type,  at  the  age  of  puberty,  are  more  sus- 
ceptible than  others  to  the  disease.  Those  under  12  or  over  20  are 
rarely  primarily  aff'ected,  but  recurrences  may  continue  for  many  years. 
The  disease  is  very  rarely  observed  in  young  boys.  Heredity  or  a  family 
influence  is  often  an  important  factor,  and  a  tubercular  taint  is  one  of 
the  most  commonly  recognized  etiological  features  in  families.  No  defi- 
nite cause  has  yet  been  recognized.  There  is  much  reason  to  look  upon 
the  disease  as  a  neurosis,  especially  the  frequency  of  the  association  of 
vasomotor  neuroses,  and  the  fact  of  its  ready  curability.  The  predis 
posing  influences  are  many.  Poor  food  and  a  disregard  of  hygiene  arc 
often  influential.  In  a  majority  of  cases,  perhaps,  there  is  an  apparently 
close  relation  between  the  establishment  of  menstruation  and  the  incep- 
tion of  the  disease.     Hypoplasia  of  the  heart  and  aorta,  not  infrequent 


ANEMIA  293 

pathological  conditions  in  these  patients,  were  regarded  b}^  Rokitanski 
and  others  as  bearing  a  causal  relation  to  it.  Constipation,  with  conse- 
quent autointoxication,  tight  lacing,  lack  of  exercise,  and  homesickness 
may  be  mentioned  among  the  theoretical  causes  that  have  been  offered. 
The  disease  commonly  develops  in  young  European  girls  soon  after 
arrival  in  this  country. 

Symptoms. — The  appearance  of  the  patient  is  much  the  same  as  in 
pernicious  anemia,  but  the  pallor  is  less  extreme  and  the  skin  has  often 
a  peculiar  yellowish  green  tinge.  The  cheeks  often  bear  a  deceptive  flush, 
and  the  mucous  membranes  may  not  reveal  the  poverty  of  the  blood 
under  the  excitement  of  the  first  examination.  The  eyes  are  brilliant 
and  the  sclerae  have  a  bluish  tint.  The  adipose  tissue  remains  nearly 
normal;  emaciation  is  exceptional.  Pigmentation  is  often  observed  in 
certain  areas,  particularly  about  the  joints.  Headache,  languor,  breath- 
lessness,  and  palpitation  are  commonly  complained  of.  The  appetite  is 
lost  or  becomes  capricious.  Nausea  and  vomiting  are  easily  induced. 
Edema  of  the  face  and  ankles,  with  cold  feet,  are  common.  Constipation 
is  almost  constant.  Gastroptosis  is  often  observed  in  girls  who  wear  the 
corset.  Dysmenorrhea  or  complete  suppression  is  commonly  present,  and 
leucorrhea  may  be  developed.  Slight  fever  is  sometimes  observed.  The 
heart  is  accelerated.  A  soft,  diffused  systolic  murmur  is  usually  heard, 
with  maximum  intensity  over  the  pulmonary  valve,  the  second  sound  of 
which  is  accentuated.  A  peculiar  venous  murmur  is  also  heard  over  the 
right  jugular  (bruit  de  diable).  Accidental  diastolic  murmurs  are  also 
occasionally  heard.  Pulsation  is  often  visible  in  the  peripheral  veins. 
Late  in  the  disease  thrombosis  may  develop  in  the  veins  of  the  lower 
extremities,  particularly  in  the  femoral,  and  rarely  in  the  cerebral  sinuses. 
Pulmonary  embolism  is  a  possible  result  of  the  thrombosis.  Nervous 
symptoms  may  also  develop,  and  the  patients  very  often  become  melan- 
cholic or  hysterical.  The  urine  generally  remains  normal  except  that  the 
solids  are  increased  and  temporary  v«iriations  of  quantity  are  commonly 
observed. 

The  blood  looks  pale  and  coagulates  readily.  The  corpuscles,  when, 
examined  under  the  microscope,  also  appear  of  light  color,  owing  to  the 
deficiency  of  hemoglobin.  The  number  of  the  red  corpuscles  is  reduced, 
but  not  as  a  rule  much  below  80  per  cent.  The  hemoglobin  may  be  as 
low  as  45  per  cent,  and  occasionally  it  is  below  40.  This  is  the  most 
characteristic  feature  of  the  condition.  Poikilocytosis,  great  irregularity 
of  size  and  shape  of  the  corpuscles,  may  be  almost  as  extreme  as  in  per- 
nicious anemia.  The  average  size  of  the  corpuscles  is  diminished.  Mega- 
loblasts  are  never  present  (Higley).  Normoblasts  are  common,  but  vary 
in  numbers  from  time  to  time.  Leucocytosis  of  moderate  degree  is  ordi- 
narily noted,  but  it  is  probably  not  important.  The  lymphocytes  are 
relatively  increased.    The  proteids  of  the  serum  are  diminished. 

Diagnosis. — The  appearance  of  the  patient,  her  age,  and  the  clinical 
history  generally  lead  to  a  correct  diagnosis,  but  they  are  not  always 
sufficient  to  diff'erentiate  it  from  the  chloranemia  of  early  tuberculosis  or 
secondary  syphilis.  That  of  the  malarial  cachexia  or  of  chronic  nephritis 
can  rarely  be  mistaken  for  chlorosis. 

Tuberculosis  can  be  distinguished  by  a  careful  physical  examination 
and  the  discovery  of  the  bacillus;  syphilis,  by  the  appearance  of  other 


294  PRACTICE  OF  MEDICINE 

characteristic  lesions.  The  blood-examination  of  malaria  reveals  some 
form  of  the  plasmodium  or  free  pigment.  Chronic  nephritis  is  rare  in 
young  girls,  and  the  condition  of  the  urine  is  pathognomonic.  From 
pernicious  anemia  the  distinction  is  usually  made  without  difficulty  by 
the  low  color  index  and  the  absence  of  megaloblasts. 

Prognosis.— The  disease  is  usually  promptly  overcome  by  early  treat- 
ment, but  recurrences  are  common,  sometimes  after  an  interval  of  several 
years.  In  some  instances,  too,  the  most  thorough  and  persistent  treat- 
ment proves  but  partially  effective. 

Treatment. — A  mild  case  will  recover  with  very  little  treatment  fur- 
ther than  rest,  the  correction  of  any  unhygienic  influence,  and  an  abun- 
dance of  good  nourishment,  consisting  largely  of  meat.  When  the  disease 
has  advanced  to  the  stage  in  which  there  are  extreme  pallor,  dyspnea, 
faintness,  anorexia,  and  amenorrhea,  the  patient  should  generally  be  con- 
fined to  bed  for  the  first  week  or  two  of  treatment.  The  diet  should  be 
easily  digestible  and  nutritious,  with  beef-juice  or  rare  beef,  milk,  and 
eggs.  If  the  home  surroundings  of  the  patient  are  unsanitary,  she  will 
do  better  in  a  hospital,  and  removal  from  the  city  to  the  country  is  al- 
ways advantageous.  Iron  is  generally  the  only  drug  that  is  required, 
and  there  is  probably  no  better  preparation  of  it  than  Blaud's  pills, 
freshly  prepared,  and  administered  in  doses  of  from  gr.  v  to  xv  (0.3 
to  i.o)  three  times  a  day.  Although  the  quantity  may  be  more  than 
theoretically  can  be  appropriated,  no  injurious  effect  is  observable  and  a 
cure  is  effected.  Many  other  preparations,  and  such  natural  waters  as 
Ronsigno  and  Levico,  containing  both  iron  and  arsenic,  have  been  highly 
extolled.  Reduced  iron  and  the  tincture  of  the  chlorid  are  often  effective. 
It  is  usually  necessary,  in  order  to  prevent  early  recurrence,  to  continue 
the  chalybeate  treatment  for  several  months  or  a  year,  but  the  maxi- 
mum dose  need  not  be  maintained.  As  soon  as  improvement  has  be- 
come apparent,  and  it  is  often  quite  prompt,  the  patient  should  be  kept 
in  the  open  air  and  sunlight  a  greater  part  of  the  day,  if  the  weather 
permit,  and  given  light  exercise. 

Other  symptoms  generally  require  treatment,  particularly  the  con- 
stipation. A  sahne  laxative,  given  regularly  every  morning,  is  generally 
the  best  remedy  for  this.  In  cases  accompanied  with  superacidity,  a 
milder  laxative  alkaline  mineral  water  may  be  taken  before  each  meal. 

II.   SECONDARY  ANEMIA. 

Secondary  anemia  is  induced  by  hemorrhage,  disease,  or  such  morbid 
states  as  inanition,  toxemia,  and  poisoning.  The  blood  is  not  primarily 
affected. 

Etiology.— (^x^  Hemorrhage  is  one  of  the  most  frequent  causes.  It 
may  be  :  (^a)  Rapid,  as  in  spontaneous  or  traumatic  lesions  of  the  blood- 
vessels, in  the  rupture  of  aneurisms,  or  in  the  erosion  of  a  vessel  in  gas- 
tric or  duodenal  ulcer,  cancer,  or  cirrhosis.  The  quantity  of  blood  lost 
may  be  so  great  as  to  cause  severe,  even  fatal,  syncope.  (<^)  It  may  be 
slow,  as  in  the  more  or  less  regular  bleeding  of  hemorrhoids,  uterine 
disease,  persistent  epistaxis,  or  from  slight  injury  in  "bleeders."  (2) 
Inanition.  This  form  of  anemia  is  more  frequently  seen  in  individuals 
who  are  prevented,  by  the  location  of  malignant  or  other  disease  of  the 


LEUKEMIA 


295 


esophagus,  from  ingesting  or  appropriating  sufficient  nourishment.  (3) 
Toxemic  anemia  occurs  in  many  of  the  acute  and  chronic  diseases,  as 
typhoid  fever,  tuberculosis,  syphiHs,  and  malarial  cachexia.  Chronic 
poisoning  by  lead,  copper,  mercury,  and  arsenic  affords  examples  of  toxic 
anemia. 

Symptoms. — The  general  symptoms  are  the  same,  to  a  varying  degree, 
as  those  of  primary  anemia.  Pallor,  vertigo,  syncope,  headache,  palpi- 
tation, prostration,  and  other  symptoms  correspond  in  severity  with 
that  of  the  condition.  After  a  hemorrhage,  all  the  elements  of  the  blood 
are  at  first  deficient.  The  water  is  rapidly  replaced,  the  corpuscles  next, 
and  the  hemoglobin  more  slowly.  In  the  anemia  following  disease  and 
toxic  conditions,  the  deficiency  may  affect  only  the  corpuscles,  and  the 
proteids  of  the  plasma,  or  the  hemoglobin  may  also  be  greatly  reduced. 
Diff'erent  conditions  are  more  or  less  peculiar  to  difi"erent  diseases.  Malig- 
nant disease  generally  produces  irregularity  in  the  form  and  size  of  the 
corpuscles  (poikilocytosis) ;  suppuration  is  attended  with  leucocytosis. 

Diagnosis. — With  a  knowledge  of  the  cause,  the  condition  is  immedi- 
ately recognizable;  without  this  it  may  be  differentiated  with  great  dif- 
ficulty from  primary  anemia. 

The  prognosis  depends  entirely  upon  the  character  of  the  cause.  Re- 
covery is  generally  spontaneous  when  this  can  be  removed. 

Treatment. — The  removal  of  the  cause,  often  a  surgical  measure,  is 
the  first  element  of  the  treatment.  After  that,  the  blood  condition  is 
promptly  restored  by  rest  and  nutritious  diet.  Medication  is  seldom 
required,  but  iron  and  arsenic  may  be  employed  in  chronic  cases. 

LEUKEMIA. 

LEUCOCVTHEMIA. 

Deffnifion. — A  disease  the  chief  feature  of  which  is  a  persistent  over- 
production of  leucocytes,  with  changes  in  the  spleen,  bone  marrow,  and 
lymphatic  glands.  The  lesions  are  often  confined  more  or  less  exclusively 
to  either  one  or  two  of  these  structures. 

Etiology. — The  disease  occurs  at  any  period  of  life,  from  earliest  in- 
fancy to  extreme  old  age,  and  in  either  sex,  but  it  is  more  frequent  in 
men  during  the  third  decade  than  in  any  others.  Women  are  oftener 
attacked  between  the  ages  of  20  and  30.  Heredity  is  regarded  as  an 
important  factor,  a  so-called  lymphogenous  diathesis  existing  in  families. 
The  disease  prevails  among  all  races  in  all  parts  of  the  world.  It  is 
more  frequent  among  the  poor  and  working  classes.  Previous  ill-health 
is  sometimes  noted,  but  it  is  not  essential.  Among  the  influences  thought 
to  predispose  to  it  are  malaria,  syphilis,  influenza,  a  tendency  to  hemor- 
rhage, digestive  disorders,  pregnancy,  and  lactation. 

The  immediate  cause  is  unknown.  The  usual  search  for  a  micro- 
organism is  going  on.  The  supposition  of  an  infectious  nature  is  in  a 
measure  supported  by  the  fact  that  the  disease  is  not  uncommon  among 
certain  of  the  lower  animals.  A  protozoon  has  been  found  in  the  leuco- 
cytes and  plasma  by  Ldwit,  who  believes  that  he  has  transmitted  the 
disease  to  animals  by  inoculation.  Certain  other  investigators  regard  it 
as  a  neoplastic  disease,  a  "sarcoma  of  the  leucocytes,"   but  neither  of 


296  PRACTICE  OF  MEDICINE 

these  views  has  received  strong  support.  An  injury  sometimes  seems  to 
be  the  exciting  cause. 

Morbid  Anaiomy. — The  body  is  extremely  emaciated;  it  may  have  a 
yellowish  or  greenish  tinge,  and  edema  with  serous  effusions  into  the 
cavities  is  common.  The  heart-chambers  and  the  veins  are  often  dis- 
tended with  coagulated  blood  which  may  have  the  appearance  of  pus 
owing  to  the  great  abundance  of  the  white  corpuscles.  The  coagula 
often  have  a  peculiar  greenish  tinge.  Charcot's  colorless,  octahedral 
crystals  often  separate  from  the  blood  in  great  numbers  after  standing. 
The  characteristic  lesions  are  found  in  the  spleen,  bone  marrow,  and 
lymphatic  glands.  In  the  most  frequent  type  (splenomyelogenous 
leukemia),  the  essential  feature  is  a  combination  of  lesions  in  the  spleen 
and  bone  marrow.  In  the  other  (lymphatic  leukemia),  lesions  of  the 
lymphatic  glands  predominate. 

The  Spleen. — Changes  in  the  spleen  are  the  most  constant.  They  are 
almost  always  associated  with  changes  in  the  bone  marrow  and  lym- 
phatic glands.  The  spleen  is  enlarged,  sometimes  greatly,  sometimes  so 
slightly  as  not  to  be  recognizable  during  life.  (^)  The  enlargement  in 
lymphatic  leukemia  is  at  first  due  to  a  hyperplasia  of  the  small  and 
large  mononuclear  cells.  The  Malpighian  bodies  were  once  regarded  as 
the  primary  seat  of  the  disease  in  these  cases.  Large,  pale,  lymphoid 
bodies  are  found  in  the  organ,  but  they  are  probably  neoplastic,  at 
least  not  Malpighian  bodies,  which  may  be  unrecognizable.  (Ji)  In  the 
myelogenous  form,  both  small  and  large  mononuclears  (myelocytes)  are 
found  in  great  numbers  in  the  spleen  as  well  as  in  the  marrow.  An 
inflammatory  condition  is  usually  set  up  which  results  in  a  chronic 
hyperplasia  of  the  connective  tissue.  The  organ  then  becomes  sclerotic 
and  the  capsule  is  often  greatly  thickened. 

The  Bone  Marrow.— The  medulla  of  the  bones,  both  long  and  flat,  loses 
its  fatty  appearance.  In  acute  cases  it  often  resembles  thick  pus,  while 
in  chronic  cases  it  is  firmer  and  lighter  in  color.  It  has  occasionall}^  a 
dark  brown  color.  Local  swellings  may  be  observed  over  the  bones, 
which  may  be  tender  and  may  yield  on  pressure.  The  essential  change  in 
the  marrow  is  a  cellular  hyperplasia  affecting  the  leucocytes  and  varying 
in  intensity  with  the  type  of  the  disease.  (<a!)  In  the  lymphatic  form  the 
lymphocytes  are  greatly  increased,  and  the  neutrophiles  and  eosinophiles 
are  comparatively  few.  The  increase  of  lymphocytes  is  not  always  ex- 
cessive, however,  and  in  some  cases  of  this  type  no  alteration  of  bone 
marrow  can  be  discovered,  (i^)  In  the  medullary  form  the  neutrophilic 
myelocytes  show  the  greatest  increase.  Eosinophiles  are  present,  but  not 
in  greatly  increased  numbers.  These  lesions  (<2  and  I?}  are  generally 
combined  and  are  rarely  encountered  separately.  The  changes  in  the 
erythrocyte  occur  for  the  most  part  in  the  advanced  stages  of  the  dis- 
ease and  are  the  same  in  character  as  those  observed  in  pernicious 
anemia,  without,  however,  so  great  increase  of  the  megaloblasts. 

The  Lymphatic  Glands. — The  lymph-glands  are  always  enlarged  in  the 
lymphatic  form  of  the  disease.  Those  of  the  cervical  region  are  most 
frequently  involved,  but  the  axillary,  inguinal,  thoracic,  and  abdominal 
glands  are  usually  affected.  The  enlargement  generally  begins  in  a 
single  gland  or  group  of  glands,  and  extends  to  others  in  proximity, 
until  the  condition  becomes  general,  including  the  follicles  of  the  mouth. 


LEUKEMIA  297 

tongue,  tonsils,  pharynx,  and  intestines.  The  glands  usually  remain 
comparatively  soft,  but  sometimes  become  quite  hard.  On  section  they 
are  white  or  pink,  but  necrosis  may  occur,  with  the  production  of  yellow- 
ish spots;  suppurative  softening  is  rare. 

On  microscopic  examination  the  enlargement  is  found  to  be  due  to 
hyperplasia  of  the  cells,  blood-channels,  and  connective  tissue.  The  pro- 
liferation sometimes  oversteps  the  limits  of  the  capsule. 

The  liver,  kidneys,  and  other  organs  are  in  some  cases  enlarged  by  a 
leukemic  infiltration.  The  skin  is  occasionally  afifected  with  an  eczema, 
which  is  followed  in  some  cases  by  tumor  formation  and  ulceration. 
Pruritus  frequently  develops  independently  of  eruptions.  Changes  are 
seldom  discovered  in  the  lungs. 

Symptoms.— The  onset  of  the  disease  is  not  usually  recognized  until 
the  glandular  enlargement,  abdominal  distention,  or  possibly  shortness  of 
breath  can  no  longer  be  overlooked.  Gastrointestinal  symptoms  may 
have  preceded  these  manifestations,  and  epistaxis  may  have  occurred.  A 
severe,  even  fatal,  hemoptysis  or  hematemesis  has  been  the  first  indica- 
tion of  the  disease  in  some  cases.  The  appearance  of  the  patient  is  not 
always  distinctive.  The  symptomatology  is  generally  described  under 
the  two  heads  of  Splenomyelogenous  and  Lymphatic  Leukemia,  corre- 
sponding to  the  two  pathological  types.  Both  these  forms  may  be 
acute  or  chronic  in  character.  Extremely  acute  cases  are  rarely  ob- 
served, as  those  terminating  fatally  in  the  initial  hemorrhage. 

I.  Splenomyelogenous  (SplenomeduUary)  Leukemia.— The  most 
prominent  feature  of  this,  the  commonest,  form  of  the  disease  is  a  pro- 
gressive enlargement  of  the  spleen.  This  may  be  accompanied  with  pain 
and  tenderness.  It  may  be  extensive,  even  enormous,  the  enlarged  organ 
occupying  more  than  half  the  adbomen  and  extending  to  the  pubis,  but 
it  varies  somewhat  in  the  same  case  from  time  to  time.  It  is  larger 
after  a  full  meal,  and  often  smaller  after  a  hemorrhage  or  profuse  diar- 
rhea. Pulsation,  a  creaking  fremitus,  and  a  murmur  have  been  observed 
in  it  in  some  instances. 

The  first  indication  of  the  disease  in  some  cases  is  pallor,  a  symptom 
which,  in  other  cases,  is  often  absent  until  comparatively  late.  Either 
subjective  symptoms  or  objective  may  be  wanting  in  a  given  case.  In 
those  of  a  given  type,  an  initial  chill  is  not  uncommon,  with  fever  and 
other  appearances  of  an  infection.  Nervous  phenomena  are  commonly 
present,  and  they  are  sometimes  the  first  indication  of  illness.  Priapism 
has  preceded  all  other  symptoms  in  some  cases  for  days  or  weeks.  Later 
headache,  vertigo,  and  fainting-spells  may  result  from  the  anemia.  Facial 
paralysis  has  been  observed,  and  rarely  an  optic  neuritis.  The  pulse  is 
generally  rapid,  but  it  may  continue  slow,  full,  and  soft.  The  heart 
may  be  displaced  upward  by  the  enlarged  spleen.  Hemorrhages  often 
occur,  as  already  noted,  and  purpuric  or  hemorrhagic  extravasations 
into  the  skin,  pleura,  peritoneum,  retina,  or  elsewhere.  Bleeding  of  the 
gums  is  common.  Pulmonary  symptoms  are  unusual,  aside  from  the 
dyspnea,  but  a  terminal  pneumonia  or  an  edema  of  the  lungs  may 
develop.    Sudden  death  without  recognizable  cause  has  been  observed. 

Disturbances  of  digestion  are  almost  constantly  present.  Nausea, 
vomiting,  diarrhea,  and  dysentery  prevail  in  different  cases.  Peritonitis 
is  sometimes  produced  by  the  formation  of  neoplastic  tissue,  and  ascites 


298  PRACTICE  OF  MEDICINE 

may  accumulate.  The  liver  usually  becomes  enlarged  in  chronic  cases. 
The  urine  shows  no  constant  change,  except  an  increase  of  uric  acid  and 
the  xanthin  bodies.  Peptonuria  and  albuminuria  have  been  observed, 
and  hematuria  in  hemorrhagic  cases.  Other  occasional  symptoms  are  : 
exophthalmos,  partial  deafness  or  tinnitus,  and  various  menstrual  dis- 
orders. 

The  Blood. — The  blood-changes  are  the  most  distinctive  feature  of  the 
disease.  In  the  splenomyelogenous  form  the  principal  change  is  the 
great  increase  of  colorless  corpuscles.  Their  ratio  to  the  red  may  be  as 
high  as  1:10,  1:5,  or  even  in  excess  of  1:1.  Their  ameboid  movements 
are  sluggish.  Their  number  varies,  from  time  to  time,  in  the  same  case. 
The  large  mononuclear  myelocytes  are  more  or  less  characteristic,  es- 
pecially the  eosinophilic  forms.  Neutrophilic  myelocytes  are  also  present, 
and  they  are  often  found  in  different  stages  of  degeneration.  The  gran- 
ules may  be  few  or  entirely  absent  in  acute  cases.  Great  differences  in 
the  size  of  the  eosinophiles  and  polynuclear  leucocytes  are  sometimes 
observed,  and  especially  in  the  polynuclear  neutrophils.  The  nuclei 
often  show  indentations  and  usually  stain  faintly.  Distinct  karyo- 
kinetic  iigures  have  been  observed  in  the  myelocytes  of  the  blood  and 
marrow. 

The  red  corpuscles  may  remain  normal,  but  in  advanced  cases  their 
number  is  generally  reduced.  They  rarely  sink  below  2,000,000  to  the 
cubic  millimeter.  Normoblasts  are  generally  present  in  large  numbers. 
Larger  cells  with  paler  nuclei  and  often  showing  karyokinetic  figures  are 
also  present.  Megaloblasts  may  be  found.  Great  variations  in  form  are 
also  observed — oval,  lanceolate,  and  irregular  forms,  sometimes  having 
fragmented  nuclei.  All  these  changes  are  well  shown  in  Plate  I,  A 
(frontispiece).  The  specimen  was  obtained  from  a  case  exhibiting  enor- 
mous enlargement  of  the  spleen  (St.  Marv's  Hospital,  service  of  Dr.  W. 
E.  Kiely). 

The  hemoglobin  sinks  with  the  reduction  of  the  red  corpuscles,  and 
sometimes  a  little  more  rapidly.  It  may  be  as  low  as  30  or  even  20 
per  cent.    It  often  shows  a  tendency  to  crystallize  on  the  slide. 

The  color  index  of  the  blood  is  reduced,  often  to  0.4  or  0.5  in  the 
early  stage  of  the  disease,  but  sometimes,  owing  to  rapid  destruction  of 
the  red  corpuscles,  toward  the  termination  it  may  rise  nearly  to  the 
normal.  It  may,  however,  continue  subnormal  throughout  the  course 
of  the  disease.  The  blood-plates  are  often  exceedingly  numerous;  they 
are  sometimes  found  in  groups  among  the  other  corpuscles. 

2.  Lymphatic  Leukemia. — This  is  rare  as  an  independent  affection. 
It  is  characterized  by  a  general  enlargement  of  the  superficial  glands. 
These  often  form  large  masses,  but  they  do  not  attain  the  great  enlarge- 
ment seen  in  Hodgkin's  disease.  Acute  cases  more  frequently  conform  to 
this  type,  but  chronic  cases  may  occur.  Lymphatic  nodules  often  form 
in  the  nose,  ear,  throat,  skin,  as  well  as  in  the  regions  of  all  the  external 
lymphatic  glands. 

The  distinctive  feature  of  the  blood  examination  in  this  form  is  the 
great  abundance  of  small  mononuclear  leucocytes,  fully  90  per  cent  of 
which  are  sometimes  lymphocytes.  Nucleated  erythrocytes  are  seldom 
present  in  large  numbers.  Mitosis  is  seldom  observed.  The  leucocytes 
rarely  exceed  1:10  of  the  red,  although  the  latter  may  be  reduced  to  50 


PSEUDOLEUKEMIA  299 

per  cent.  Eosinophiles  are  rare;  myelocytes  are  usually  absent.  These 
features  may  be  studied  in  Plate  I,  B. 

Various  disturbances  are  produced  by  the  glandular  and  other  infil- 
trations. Cough  and  dyspnea  follow  the  enlargement  of  the  bronchial 
glands ;  tenderness  of  the  long  bones  may  result  from  their  infiltration ; 
ocular  disturbances,  from  infiltration  of  the  retina,  and  deafness  from 
the  nodular  formations  in  the  ear.  The  spleen  is  almost  always  en- 
larged, but  not  to  the  extreme  degree  that  is  seen  in  the  other  form  of 
the  disease. 

Very  similar  to  leukemia  is  the  highly  fatal  chloroma,  or  green  cancer. 
It  is  characterized  by  the  formation  of  grass-green,  yellowish,  or  grayish- 
green  tumors  behind  the  eyeball,  causing  exophthalmos,  and  in  other 
regions.  The  nodules  resemble  those  of  leukemia,  pseudoleukemia,  or 
multiple  myeloma,  another  rare  affection  probably  of  the  same  class.  In 
some  cases  changes  in  the  blood  like  those  of  leukemia  and  a  tendency 
to  hemorrhage  have  been  observed.  A  green  coloring  matter  is  some- 
times found  in  the  urine. 

Diagnosis. — The  recognition  of  leukemia  and  that  of  its  separate 
forms  depends  upon  the  microscopic  examination  of  the  blood.  In  both 
forms  there  is  great  increase  in  the  number  of  leucocytes,  more  extreme 
in  the  splenomyelogenous  than  in  the  lymphatic.  Myelocytes  predomi- 
nate in  the  former,  lymphocytes  in  the  latter. 

Prognosis. — The  prognosis  is  unfavorable.  Recovery  is  possible,  but 
the  disease  usually  progresses  slowly  to  a  fatal  termination  in  the  course 
of  two  or  three  years.  Its  progress  is  not  uniform,  however.  Intervals 
of  apparent  improvement  frequently  occur.  The  lymphatic  form  is 
generally  more  izapidly  fatal.  The  occurrence  of  hemorrhage,  persistent 
diarrhea,  high  temperature,  and  edema  are  particularly  unfavorable 
signs. 

Treatment — The  treatment  is  in  many  respects  the  same  as  that  of 
pernicious  anemia.  The  patient  should  be  given  physical  and  mental 
rest,  an  abundance  of  fresh  air  and  sunshine,  and  nutritious  food.  Ar- 
senic is  often  beneficial,  but  it  has  not  the  specific  action  which  it  so 
often  exhibits  in  pernicious  anemia.  It  should  be  given  in  increasing 
doses.  Iron  and  quinin  are  often  of  apparent  benefit.  Inhalations  of 
oxygen  have  been  followed  by  at  least  temporary  improvement.  The 
natural  tendency  of  the  disease  to  intervals  of  improvement  should  be 
borne  in  mind. 

PSEUDOLEUKEMIA 

HODGKIN'S     DISEASE,    MALIGNANT     LYMPHOSARCOMA,    MULTIPLE     MALIG- 
NANT  LYMPHOMA. 

Definition. — A  chronic  progressive  form  of  anemia  with  marked  en- 
largement of  the  lymphatic  structures  and  spleen,  often  accompanied 
with  a  growth  of  lymphoid  formations  in  the  liver  and  other  organs. 

Etiology.— The  disease  usually  attacks  the  young.  It  is  not  uncom- 
mon in  infancy  and  childhood;  75  per  cent  of  the  cases  occur  between 
the  ages  of  i  o  and  40,  and  but  few  after  the  latter  age.  Men  are  much 
more  commonly  aff'ected.  A  hereditary  influence  often  seems  probable. 
Previous  illness,  as  syphilis  and  malaria,  are  possible,  but  very  uncertain 


300  PRACTICE  OF  MEDICINE 

factors.  No  definite  cause  is  known.  In  some  instances  the  disease 
develops  at  first  locally  at  some  point  of  prolonged  irritation,  as  about 
a  decayed  tooth,  or  follows  a  chronic  nasal  catarrh  or  chronic  skin 
disease,  but,  as  a  rule,  its  invasion  is  insidious.  The  disease  has  been  re- 
garded by  some  writers  as  an  infectious  granuloma  similar  to  leprosy. 
Some  have,  indeed,  divided  it  into  two  forms,  one  tubercular  and  charac- 
terized by  a  febrile  course,  the  other  sarcomatous.  Sternberg  regards  it 
as  essentially  tubercular,  while  other  investigators  have  looked  upon  the 
presence  of  tubercle  bacilli  in  the  lesions  as  accidental.  It  is  possible 
that  several  diseases  are  still  included  under  this  heading. 

Morbid  /In atomy.— The  lesions  are  found  particularly  in  the  lymphatic 
glands  and  the  spleen.  The  lymphatic  glands  of  the  entire  body  are 
sometimes  enlarged.  Among  the  superficial  glands  the  most  prominent 
are  those  of  the  neck,  axilla,  and  groin;  among  the  deep  glands,  the 
bronchial,  mediastinal,  and  retroperitoneal.  The  nodules  are  generally 
soft,  but  may  become  extremely  firm.  In  size  they  may  exceed  an  egg, 
many  smaller  nodules  generally  being  present.  Even  when  they  are  hard 
their  interior  is  generally  soft  and  often  caseous.  The  capsule  is  some- 
times ruptured  by  the  increasing  growth.  In  rare  instances  the  sternum 
and  vertebrae  have  been  penetrated  and  the  spinal  cord  has  been  pressed 
upon.  The  enlargement  consists  of  a  hyperplasia  of  the  lymph-cells. 
The  reticulum  may  be  thickened,  but  it  is  sometimes  almost  undistin- 
guishable  in  the  softer  nodules.  The  bone  marrow  may  be  pus-like,  as  in 
pernicious  anemia. 

The  spleen  is  enlarged  in  75  per  cent  of  all  cases,  but  not  to  the  ex- 
tent characteristic  of  true  leukemia.  The  hypertrophy  is  due  to  the 
growth  of  grayish  white  lymphoid  bodies  varying  in  diameter  from  ys  to 
ii/^  inches  (0.5—4.0  cm.),  and  composed  of  lymphoid  corpuscles  m  a 
fibrous  reticulum.  Similar  lymphoid  growths  are  sometimes  found  in  the 
tonsils,  thyroid  gland,  thymus,  lungs,  liver,  kidneys,  adrenals,  and  skin, 
and  rarely  in  the  solitary  follicles  of  the  intestine,  in  the  brain,  retina, 
and  testicle. 

5//77/;/o/ns.— Enlargement  of  the  cervical  glands  is  usually  the  first 
symptom  to  attract  attention;  occasionally  this  is  accompanied  with 
similar  swelling  of  the  axillary  and  inguinal  groups.  The  disease  may 
extend  next  to  the  glands  of  the  opposite  side  or  to  those  of  other 
groups.  An  acute  onset  and  rapid  progress  are  occasionally  observed. 
Angina  with  enlargement  of  the  tonsils  has  constituted  the  beginning  of 
some  cases.  In  other  cases,  again,  the  deep-seated  glands  of  the  thorax 
have  been  the  starting-point,  and  the  first  symptoms  have  been  those  of 
pressure  upon  the  bronchi,  with  dyspnea  and  cough;  pressure  on  the 
vena  cava  with  venous  engorgement  of  the  upper  part  of  the  body  and 
the  development  of  visible  anastomoses,  or  pressure  upon  the  cervical 
sympathetic,  with  inequality  of  the  pupils.  Very  exceptionally,  edema  of 
the  lower  extremities,  shooting  pains  or  paraplegia,  due  to  pressure 
upon  the  veins  and  spinal  cord,  have  been  the  initial  manifestations. 
With  the  increasing  enlargement  of  the  glands  the  patient  becomes  more 
markedly  anemic.  He  rapidly  loses  strength,  he  often  suffers  with  head- 
ache, palpitation,  tinnitus,  vertigo,  dyspnea  on  exertion,  loss  of  appetite, 
and  other  disturbances  due  to  the  anemia.  The  deformity  produced  by 
the  enlargement  of  the  glands  of  the  neck  is  often  extreme  and  charac- 


PURPURA  301 

teristic,  entirely  obliterating  the  contour  of  the  cervical  and  clavicular 
regions.  In  like  manner,  large  tumors  may  be  formed  in  the  axillae  and 
groins.  The  internal  glands  can  usually  be  felt  in  a  thin  person.  A 
peculiar  feature  is  an  absence  of  uniformity  in  its  progress;  there  is  often 
a  cessation  of  the  growth  of  the  glands  or  even  a  reduction  of  their 
size.  The  clinical  features  of  the  disease  are  exceedingly  variable,  owing 
to  differences  in  the  extent  of  the  lesions  and  their  locations.  Moderate 
fever  is  sometimes  a  prominent  feature  in  tubercular  cases.  It  is  usually 
of  an  irregular,  intermittent,  type,  rarely  continuous. 

The  spleen  is  enlarged  to  a  variable  extent  in  most  cases.  The  in- 
crease of  size  may  come  on  slowly  or  with  remarkable  rapidity,  and  the 
same  lack  of  uniformity  is  exhilDited  as  in  the  lymphatic  glands.  In 
extreme  cases,  especially  in  those  occurring  in  children,  the  organ  may 
extend  down  to  the  brim  of  the  pelvis.  Some  writers  regard  the  splenic 
anemia  of  the  German  authors,  in  which  the  spleen  alone  is  enlarged,  as 
a  form  of  pseudoleukemia. 

The  Blood. — In  some  cases  the  blood  remains  normal,  except  that  the 
hemoglobin  is  reduced.  This  deficiency  is  seldom  below  60  per  cent. 
The  eosinophiles  and  mononuclears  are  generally  relatively  increased,  es- 
pecially in  febrile  cases.  A  few  myelocytes  are  occasionally  observed. 
Hemic  murmurs  are  sometimes  heard  over  the  heart.  The  urine  gener- 
ally remains  normal.  Bronzing  of  the  skin  is  occasionally  noted,  ap- 
proaching, in  severe  cases,  the  color  of  Addison's  disease. 

Diagnosis. — The  diagnosis  rests  upon  the  blood  examination,  based 
upon  the  distinctions  just  given.  Simple  tubercular  adenitis  is  more 
common  in  children,  more  frequently  affects  the  submaxillary  than  the 
cervical  and  axillary  glands,  and  is  generally  slower  of  extension.  Yet 
acute  cases  are  observed.  Syphilitic  adenitis  is  recognizable,  as  a  rule,  by 
the  history,  the  presence  of  other  symptoms,  and  the  greater,  or  ex- 
clusive, enlargement  of  the  posterior  cervical  glands. 

Prognosis. — The  prognosis  is  highly  unfavorable.  Recovery  has  been 
reported,  but  the  progress  of  the  disease  is  fatal  and  the  intervals  of 
apparent  improvement  deceptive.  The  glandular  swellings  sometimes 
subside  almost  completely  shortly  before  death.-  Fever,  rapid  emaciation 
and  great  prostration,  with  pressure  symptoms  or  hemorrhages,  are 
unfavorable  indications. 

Treatment. — Arsenic  is  generally  employed  in  the  treatment,  but  its 
action  is  less  marked  in  advanced  cases.  The  apparent  results  often 
prove  fallacious.  Quinin,  iron,  codliver  oil,  phosphorus,  and  strychnin 
are  of  benefit  in  some  cases.  Local  applications  of  iodin  ointment  or 
tincture,  or  of  mercurial  preparations,  and  the  galvanic  current  over  the  ■ 
tumors,  have  been  followed  by  more  or  less  continued  reduction  of  their 
size.  The  expediency  of  early  excision  of  the  glands  should  be  consid- 
ered.    Several  recoveries  have  followed  removal  of  the  spleen. 

PURPURA. 

MORBl'S    MACULOSUS. 

The  term  purpura  is  applied  generically  to  a  group  of  conditions  in 
which,  without  serious  impairment  of  health,   hemorrhages  occur  into 


302  PRACTICE  OF  MEDICINE 

the  skin  of  a  greater  or  less  portion  of  the  body.  The  hemorrhagic 
spots  may  be  punctate  (petechial)  or  of  the  nature  of  ecchymoses, 
seldom  exceeding  an  inch  in  diameter.  In  color  they  pass  from  a 
bright  red  to  a  dark  brown.  They  do  not  disappear  upon  pressure. 
Such  eruptions  are  not  of  infrequent  occurrence  in  various  infectious, 
toxic,  cachectic,  and  nervous  conditions.  The  purpura  is  then  referred 
to  as  secondary  or  symptomatic.  Several  so-called  primary  forms  are 
also  observed. 

1.  Symptomatic  Purpura.— C^^)  Infectious.—T\vQXck.'s^  of  typhus  fever  is 
normally  petechial;  the  eruptions  of  measles,  smallpox,  and  other  ex- 
anthemata are  occasionally  hemorrhagic.  Distinctly  hemorrhagic  erup- 
tions may  occur  also  in  connection  with  cerebrospinal  meningitis,  septice- 
rhia,  typhoid  fever,  malignant  endocarditis,  and  in  such  chronic  affections 
as  leukemia,  pseudoleukemia,  pernicious  anemia  and  tuberculosis.  (Ji) 
Among  toxic  cases  are  those  resulting  from  snake  venom  or  such  drugs 
as  potassium  iodid,  chloral,  ergot,  quinin,  copavia,  or  belladonna,  or  in 
association  with  jaundice,  (r)  Cachectic  cases  occur  in  connection  with 
malignant  disease,  scurvy,  chronic  nephritis,  and  in  extreme  old  age. 
(^)  Neurotic  purpura  is  met  with  in  connection  with  neuralgia,  hysteria, 
locomotor  ataxia,  acute  and  transverse  myelitis.  (^)  In  another  group 
are  sometimes  included  cases  of  mechanical  purpura  resulting  from 
obstruction,  venous  stasis,  and  extravasation  of  blood  from  violent 
effort,  as  in  whooping-cough  or  convulsions.  (See  also  Hemorrhage, 
p.  14.) 

2.  Arthritic  Purpura. — Under  this  heading  are  grouped  three  classes 
of  cases,  in  all  of  which  more  or  less  involvement  of  the  joints  is  gener- 
ally observed  : 

"  (a)  Purpura  Simplex.— This  is  a  mild  form  of  the  affection,  occur- 
ring almost  exclusively  in  children,  and  sometimes  without  arthritic 
manifestations.  The  patients  are  generally  anemic  and  the  condi- 
tion is  often  accompanied  with  digestive  disturbances  and  diarrhea. 
The  joints  are  swollen  and  painful  in  some  cases,  but  fever  is  unusual. 
The  purpuric  spots  appear  on  the  legs,  less  frequently  on  the  arms  and 
trunk. 

(^f)  Purpura  Pheumatica  (Peliosis  Rheumatica;  Schonlein's  Disease). 
—This  affection  attacks  chiefly  men  between  20  and  40  years  of  age,  and 
more  commonly  those  who  have  been  debilitated  by  previous  illness.  A 
rheumatic  history  may  be  obtained.  It  is  generally  associated  with 
distinct  articular  pains  and  swelling  which  are  regarded  as  rheumatic  in 
nature,  a  supposition  favored  by  the  fact  that  tonsilitis,  endocarditis,, 
and  pericarditis  are  occasional  complications.  Fever  amounting  to  102° 
or  103°  F.  (38.8°— 39.5°  C.)  is  generally  present.  The  eruption  appears 
about  the  legs  and  on  the  affected  joints,  but  it  is  not  uniformly  pur- 
puric. Urticaria  (purpura  urticans),  erythema  with  hemorrhagic  extrav- 
asation, or  a  vesication  like  that  of  pemphigus  is  sometimes  met  with. 
Edema,  of  the  feet  and  ankles  is  seen  in  some  cases  and  the  face  may 
become  edematous.  The  term  febrile  purpuric  edema  has  been  applied  to 
cases  in  which  fever  is  also  present.  The  patient  is  anemic,  loses  his 
appetite,  and  becomes  prostrated.  Digestive  disorders  are  common.  The 
urine  becomes  scant  and  is  often  albuminous. 

'    (^)   Henoch'' s  disease  is  a  recurrent  form  of  purpura,  seen,  for  the  most 


PURPURA  303 

part,  in  children.  It  is  accompanied  with  gastrointestinal  disturbances, 
slight  swelling  of  the  joints  sometimes  with  renal  symptoms,  and  hem- 
orrhages from  the  mucous  membranes,  the  bowels,  or  kidneys.  Enlarge- 
ment of  the  spleen  is  common.  The  disease  is  sometimes  fatal,  espe- 
cially in  adults,  but  as  many  as  a  dozen  recurrences  may  take  place 
without  fatal  result. 

3;  Purpura  Hemorrhagica  (Morbus  Maculosus  Werlhofi).— This,  the 
most  serious  form  of  purpura,  is  generally  seen  in  young,  delicate  girls, 
but  vigorous  adults  are  not  exempt  from  it.  Poorly  nourished  indi- 
viduals exposed  to  cold  and  damp  dwellings,  and  those  recovering  from 
illness,  are  thought  to  be  more  susceptible  than  others.  Such  toxic 
agents  as  iodin,  mercury,  silver,  and  phosphorus  have  been  regarded  as 
the  exciting  cause  in  some  cases.  An  infectious  origin  has  also  been 
supposed  to  exist. 

Symptoms. — The  onset  of  the  affection  may  be  sudden  and  severe, 
usually  announced  by  great  weakness,  an  eruption  of  purpuric  spots,  and 
hemorrhages  from  the  mucous  membranes.  An  initial  epistaxis  may 
occur.  In  severe  cases  the  patient  becomes  almost  exsanguinated,  and 
death  may  ensue  from  the  loss  of  blood  or  from  hemorrhage  into  the 
brain.  Eruptions  like  those  seen  in  rheumatic  purpura  are  usually 
present.  The  blood  presents  nothing  distinctive,  except  marked  increase 
of  the  time  required  for  its  coagulation,  often  amounting  to  ten  or 
fifteen  minutes.  After  the  hemorrhages  there  is  a  pronounced  oligemia, 
and  for  a  time  the  hemoglobin  remains  reduced. 

A  fulminant  form  of  purpura  hemorrhagica  is  sometimes  encountered 
in  which,  with  a  profuse  cutaneous  eruption,  but  without  actual  loss  of 
blood  from  any  of  the  mucous  membranes,  a  fatal  prostration  is  pro- 
duced, death  sometimes  occurring  within  the  first  24  hours. 

Diagnosis. — The  disease  is  not  usually  dii^cult  of  recognition,  but  it  is 
sometimes  extremely  difficult  to  determine  whether  a  case  is  one  of  pure 
purpura  hemorrhagica,  a  leukemia  with  hemorrhagic  symptoms,  or  a 
toxic  purpura  associated  with  an  acute  infectious  disease.  It  is  some- 
times impossible  for  a  few  days  to  arrive  at  a  positive  diagnosis.  As  a 
rule,  however,  the  glandular  and  splenic  enlargements  differentiate  leu- 
kemia, and  the  prodromal  symptoms  an  acute  infection. 

The  prognosis  must  always  be  guarded,  for  it  is  never  possible  to 
predict  the  course  of  the  disease. 

Treatment — In  the  symptomatic  form  the  treatment  is  chiefly  that  of 
the  underlying  condition.  Sodium  salicylate  should  be  administered  in 
rheumatic  cases,  and  arsenic  in  simple  purpura.  The  arsenic  should  be 
given  in  increasing  doses  until  slight  toxic  effects  begin  to  appear.  Er- 
got, lead  acetate,  turpentine,  aromatic  sulphuric  acid,  gallic  acid,  and 
other  agents  have  been  employed  with  uncertain  success  to  control  the 
hemorrhages.  Calcium  chlorid  in  doses  of  gr.  xx  (1.30)  every  four 
hours  has  been  regarded  as  beneficial  in  increasing  the  coagulability  of 
the  blood.  When  the  hemorrhage  is  from  an  exposed  point,  as  in  the 
mouth  or  nose,  irrigations  with  a  2  per  cent  gelatin  solution,  or  the 
application  of  a  solution  of  adrenalin  or  of  the  suprarenal  extract 
should  be  resorted  to.  Fuller's  success  with  the  internal  administra- 
tion of  thyroid  extract,  in  full  doses,  in  hemophilia  suggests  the  possi- 
bility of  beneficial  action  also  in  this  condition.    After  the  hemorrhages 


304  PRACTICE  OF  MEDICINE 

have  been  arrested,  the  strength  of  the  patient  should  be  built  up  with 
tonics  and  nutritious  food,  remedies  for  the  digestion  being  administered 
if  necessary.    Iron  and  arsenic  are  of  service  in  preventing  recurrences. 

HEMOPHILIA. 

Definiiion. — A  hereditary  constitutional  affection  marked  by  a  ten- 
dency to  bleed  spontaneously  or  after  slight  injury.  The  hemorrhages 
are  generally  severe,  sometimes  uncontrollable  and  fatal. 

Etiology. — In  a  great  majority  of  instances  the  disease  is  recognized 
in  early  life,  but  it  may  not  become  manifest  until  as  late  as  the  twen- 
tieth year,  or  later.  The  hemorrhagic  tendency  is  generally  more 
marked  in  the  male  members  of  the  family,  if  not  confined  exclusively 
to  them.  It  is  transmitted,  as  a  rule,  by  the  female  to  her  male  offspring, 
although  she  may  not  be  herself  a  bleeder.  The  disease  is  handed  down 
through  families,  sometimes  as  far  as  the  seventh  generation.  It  has 
rarely  been  transmitted  from  father  to  son.  The  disease  has  been  met 
with  in  all  parts  of  the  world,  and  among  people  of  every  station.  It 
seems  to  be  more  common,  however,  in  the  Anglo-German  races,  in  cold 
climates,  and  it  is  more  frequently  developed  in  the  spring  and  autumn. 
No  specific  cause  is  known. 

Morbid  Anatomy.— Tht  morbid  condition  apparently  lies  in  the  pe- 
culiar type  of  blood-vessel  rather  than  in  the  blood.  Bleeders  are 
generally  well  developed  and  apparently  healthy,  but  they  have  delicate 
skin  and  thin  blood-vessels.  In  some  cases,  at  least,  the  middle  mus- 
cular coat  of  the  vessels  has  been  found  extremely  thin.  The  blood  is 
usually  normal,  so  far  as  can  be  determined.  An  increase  of  the  number 
of  erythrocytes  has  been  observed  in  some  instances.  The  coagulability 
of  the  blood  is  so  far  reduced  in  some  cases  that  30  to  45  minutes  are 
required  for  the  formation  of  a  clot.  The  leucocytes  and  blood-plates 
have  also  been  found  deficient. 

Symptoms. — The  distinctive  symptom  is  the  tendency  to  persistent 
hemorrhages,  occurring  spontaneously  or  following  some  trivial  injury, 
as  the  scratch  of  a  pin,  a  cut,  or  bruise.  Fatal  hemorrhage  has  followed 
the  extraction  of  a  tooth  or  the  operation  of  circumcision.  A  spontane- 
ous hemorrhage  more  frequently  assumes  the  form  of  an  epistaxis,  but 
it  may  originate  in  the  lungs,  stomach,  bowels,  urethra,  or  from  any  of 
the  other  mucous  membranes.  Severe  hemorrhages  sometimes  occur  at 
the  menstrual  period  or  after  parturition  in  women  thus  affected,  but  it 
is  a,  remarkable  fact  that  they  are  very  exceptional.  The  bleeding  in  any 
case  may  continue  for  several  days  and  cease  spontaneously,  to  be  fol- 
lowed by  prompt  recovery,  but  a  condition  of  profound  anemia  some- 
times remains. 

Arthritic  symptoms  occasionally  accompany  the  hemorrhages,  the 
large  joints  becoming  swollen  and  painful.  Blood  is  sometimes  extrava- 
sated  into  them.  A  febrile  synovitis  is  sometimes  developed,  and  it  may 
leave  the  joints  stiff  and  deformed.  Petechiae,  ecchymoses,  and  large 
hematomata  are  sometimes  formed  in  various  regions  as  a  result  of  the 
extravasations. 

Diagnosis. — The  diagnosis  is  based  upon  a  persistent  tendency  to  pro- 
fuse hemorrhages  when  it  can  be  traced  to  a  hereditary  influence.    This 


HEMORRHAGIC  DISEASES  OF  THE  NEWBORN  305 

is  more  commonly  possible  when  there  is  simultaneous  involvement  of 
the  articulations.  The  distinction  between  this  disease  and  the  different 
forms  of  purpura  is  not  usually  difficult,  except  in  some  cases  of  pur- 
pura rheumatica  or  in  the  absence  of  a  definite  family  history. 

The  prognosis  is  relatively  less  favorable  in  young"  persons.  The 
later  the  disease  becomes  manifest,  the  greater  is  the  possibility  of  its 
being  outlived.  Children  showing  the  hemorrhagic  tendency  early  seldom 
attain  the  age  of  puberty. 

Treatment. — It  is  not  always  possible  to  protect  the  bleeder  from  the 
trivial  accidents  which  may  induce  a  serious  hemorrhage,  but  surgical 
operations  of  every  kind  should  be  avoided.  Even  vaccination  should  be 
performed  with  care  in  order  not  to  start  a  persistent  oozing.  The 
female  members  of  the  family,  particularly,  should  be  advised  against 
marriage. 

When  a  hemorrhage  has  been  induced,  the  patient  should  be  confined 
to  bed  and  given  complete  rest.  Ice  and  astringents  may  be  applied 
when  possible.  Fuller  has  recently  found  the  administration  of  thyroid 
extract  immediately  effective  in  a  typical  case,  arresting  the  hemorrhage 
and  apparently  overcoming  the  tendency.  It  should  be  given  in  doses  of 
gr.  V  (0.30)  t.  i.  d.  to  an  adult.  If  this  remedy  prove  unsuccessful,  resort 
must  be  had  to  the  older  remedies — iron,  gallic  acid,  lead  acetate,  and 
other  astringents  and  styptics.  WTien  the  bleeding  area  is  accessible, 
solutions  of  adrenalin,  the  suprarenal  extract,  or  gelatin  may  be  applied. 
Transfusion  has  not  proved  successful.  During  the  intervals  an  attempt 
may  be  made  to  overcome  the  tendency  by  the  administration  of  iron 
and  arsenic. 

HEMORRHAGIC  DISEASES  OF  THE  NE\¥-BORN. 

Epidemic  Hemoglobinuria  (Winckel's  Disease).— This  disease  occurs 
epidemicaJly  in  lying-in  hospitals,  among  infants  from  one  to  ten  days 
old.  The  infants  become  jaundiced,  feverish,  refuse  nourishment,  and 
rapidly  become  cyanotic.  The  urine  is  scant,  high-colored,  and  contains 
methemoglobin  and  albumin.  Hemorrhages  occur  into  various  organs. 
The  origin  of  the  disease  is  not  known;  investigations  have  failed  to 
establish  a  supposed  septic  cause.  Acute  fatty  degeneration  of  the  in- 
ternal organs  (Buhl's  disease)  is  frequently  associated  with  it. 

Syphilis  Hemorrhagica  Neonatorum.— This  affection  occurs,  in  connec- 
tion with  jaundice,  in  young  syphilitic  infants.  At  birth,  or  soon  after- 
ward, ecchymotic  spots  appear,  and  hemorrhages  occur  from  the  um- 
bilicus and  mucous  membranes. 

Morbus  Maculosus  Neonatorum.— This  term  has  been  applied  to  fatal 
hemorrhages  from  the  umbilicus,  gastrointestinal  canal,  or  nose,  and  to 
simultaneous  bleeding  from  all  these  sources,  during  the  first  week  or 
two  after  birth.  The  disease  usually  runs  a  rapidly  fatal  course;  some- 
times it  is  attended  with  fever.  Intense  icterus  is  sometimes  present. 
Its  cause  and  nature  are  unknown.  The  probability  of  infection  as 
its  cause  is  inferred  from  its  general  occurrence  in  hospitals.  In  the 
diagnosis  of  some  cases  of  infantile  hematemesis  it  is  necessary  to 
exclude  the  vomiting  of  blood  which  has  been  drawn  from  the  nipple  of 
the  mother. 


3o6  PRACTICE  OF  MEDICINE 

SCURVY. 

SCORBUTUS. 

Definition. — A  subacute  or  chronic  disease  the  prominent  features  of 
which  are  inanition,  anemia,  debihty,  a  swollen,  spongy  condition  of 
the  gums,  and  a  tendency  to  hemorrhages. 

Eiiology. — The  disease  may  develop  at  any  period  of  life.  Infants 
were  practically  exempt  from  it  until  the  practice  uf  artificial  feeding 
became  prevalent,  and  it  is  now  a  common  affection  of  early  life.  There 
is  probably  no  difference  in  the  susceptibility  of  the  sexes,  but  men  are 
more  commonly  exposed  to  the  privations  which  induce  the  disease  and 
are,  therefore,  more  frequently  affected.  The  important  etiological  factor 
in  all  cases  is  malnutrition,  from  improper  food.  The  disease  was  for- 
merly exceedingly  common  among  soldiers  and  sailors  who  were  com- 
pelled to  subsist  for  a  long  time  upon  a  restricted  diet.  Since  the  im- 
portance of  a  proper  diet  has  become  recognized,  however,  the  disease 
is  much  less  prevalent.  It  is  still  seen  occasionally  in  the  hospitals  of 
seaports,  among  the  inmates  of  penal  institutions  and  asylums,  and 
among  the  foreign  population  of  mining  districts. 

There  are  two  theories  of  its  origin,  one  attributing  it  to  the  improper 
food,  and  the  other  to  an  unknown  form  of  infection. 

(i)  Improper  Food. — The  precise  nature  of  the  deficiency  among  the 
ingredients  of  the  food  is  not  known,  (ji)  It  is  generally  believed  to  be 
an  absence  of  the  ingredients  supplied  by  fresh  vegetables  and  fruits, 
but  whether  it  is  the  lack  of  organic  or  of  inorganic  salts  is  still  uncertain. 
(Ji)  The  presence  of  toxic  matter  in  the  food  as  a  result  of  decomposi- 
tion is  also  a  possible  cause.  Experiments  by  Vaughan  and  others  lend 
strong  support  to  the  latter  view  and  place  the  disease  in  close  relation- 
ship with  ptomain-poisoning.  (J)  That  the  disease  is  induced  by  the 
excessive  eating  of  salted  meats,  at  least  so  far  as  the  introduction  of 
too  great  an  amount  of  sodium  chlorid  is  concerned,  is  no  longer  re- 
garded as  tenable. 

(2)  Infedmi.—^o  specific  organism  has  been  discovered  by  those  who 
regard  the  disease  as  an  infection.  The  theory  is  supported  mainly  by 
the  epidemic  occurrence  of  the  disease,  the  unsanitary  conditions  to  which 
its  victims  have  been  exposed  being  looked  upon  as  a  predisposing 
cause,  preparing  the  system  for  infection.  Such  clinical  features  as 
purpura  and  hemorrhages  add  some  weight  to  it.  There  is  no  evidence 
of  contagiousness. 

Certain  predisposing  influences  are  well  recognized,  as  dwelling  in 
damp  apartments,  overcrowding,  mental  depression,  physical  fatigue, 
worry,  grief,  homesickness,  and  such  diseases  as  malaria,  syphilis,  and 
dysentery. 

Morbid  Anatomy. — Extensive  pathological  lesions  are  often  found, 
but  they  are  not  characteristic  of  the  disease.  The  body  may  be  ex- 
tremely emaciated  and  mottled  with  ecchymoses,  the  ankles  puffed  with 
edema.  The  blood  may  be  fluid  or  partly  coagulated;  degenerative 
changes  are  usually  found  in  the  larger  extravasations;  suppuration  is 
rare.  The  blood-count  shows  nothing  distinctive.  Hemorrhagic  accu- 
mulations are  found  in  the  mucous  membranes,  muscles,  and  internal 
organs.  The  gums  show  characteristic  swelling  and  sometimes  ulceration; 


SCURVY  307 

some  of  the  teeth  may  have  fallen  out,  or  they  may  remain  loosely 
attached.  The  spleen  is  large  and  soft.  Parenchymatous  degeneration 
is  commonly  found  in  the  heart,  liver,  and  kidneys.  The  lymphatic 
glands  are  not  usually  involved,  but  those  of  the  mesentery  may  be 
swollen  when  the  intestinal  mucous  membrane  is  affected. 

Symptoms. — The  onset  of  the  disease  is  generally  preceded  by  pro- 
dromal symptoms  on  the  part  of  the  gastrointestinal  system,  accompa- 
panied  with  pallor,  emaciation,  and  weakness.  Soreness  of  the  throat 
or  a  severe  internal  hemorrhage  may  be  the  first  indication  of  it.  In 
many  instances  the  condition  of  the  gums  is  the  first  symptom  to 
attract  attention.  This  is  characterized  by  swelling  and  a  spongy  con- 
dition which  renders  them  liable  to  bleed  upon  the  slightest  irritation. 
The  swelling  begins  about  the  incisor  teeth  and  spreads  to  the  other 
parts ;  in  severe  cases  it  may  be  so  extreme  as  to  completely  conceal  the 
teeth  from  view.  A  pseudomembranous  growth  is  sometimes  noted  on 
the  surface.  Actual  ulceration  is  not  common,  but  the  teeth  become 
loose  and  are  sometimes  lost.  The  tongue  becomes  swollen  and  red, 
and  the  breath  is  extremely  fetid.  Hemorrhagic  spots  appear  in  the 
mucous  membranes,  and  bleeding  often  occurs,  usually  in  the  form  of 
oozing.  Epistaxis  occasionally  occurs ;  hemoptysis  and  hematemesis  are 
unusual.  The  salivary  glands  may  be  enlarged.  The  saliva  flows  in 
increased  quantity,  and,  mingled  with  blood,  it  often  escapes  from  the 
mouth.  The  skin  is  pale,  cool,  dry,  and  sometimes  has  a  slightly  yellow 
hue.  Ecchymoses  soon  appear  upon  the  legs,  then  on  the  arms  and 
trunk.  Petechise  form  in  and  about  the  hair  follicles.  Irregular  nodules 
are  often  formed  on  the  legs  by  effusions  between  the  periosteum  and 
bone,  and  they  sometimes  break  down  to  form  uncleanly  ulcers.  Slight 
injury  induces  hemorrhage.  Edema  of  the  ankles  is  usually  present. 
In  severe  cases  the  infiltration  into  the  subcutaneous  and  intermuscular 
tissues  of  the  legs  leads  to  a  firm  induration,  and  this  may  be  followed 
by  hyperplasia  of  the  connective  tissue,  which  leaves  permanent  stiffness 
and  loss  of  motion,  particularly  in  the  region  of  the  joints  (scurvy 
sclerosis).  Necrosis  of  the  bones  and  epiphyseal  separations  sometimes 
occur  in  advanced  cases. 

The  gastrointestinal  tract  is  affected  to  a  variable  extent.  Thirst 
is  often  extreme;  the  stomach  is  irritable  and  there  is  often  a  craving 
for  sour  or  highly  seasoned  articles,  or  the  appetite  may  be  suppressed. 
Constipation  is  the  rule,  but  diarrhea  or  the  scurvy  dysentery  may 
supervene.  The  action  of  the  heart  is  generally  feeble,  and  a  hemic 
bruit  may  be  heard  over  the  base.  Hemorrhagic  infarction  sometimes 
forms  in  the  lungs  or  spleen.  The  urine  becomes  scant,  dark,  concen- 
trated, and  often  albuminous.  Headache,  lassitude,  mental  depression, 
and  finally  delirium  or  coma  are  often  noted  toward  the  close.  Hemi- 
plegia, convulsions,  or  other  nervous  complications  may  develop. 
Hemeralopia  (day-blindness)  or  nyctalopia  (night-blindness)  is  an 
occasional  symptom,  sometimes  developing  early  in  sailors.  The  disease 
generally  runs  an  afebrile  course,  except  as  fever  may  result  from  the 
inflammatory  processes  induced  by  the  hemorrhagic  infiltrations  in  the 
organs. 

Diagnosis. — The  diagnosis  of  scurvy  is  based  upon  the  history  of  the 
case,  the  stupor,  the  peculiar  condition  of  the  gums,  and  hemorrhages, 


3o8  PRACTICE  OF  MEDICINE 

emaciation,  weakness,  and  finally  the  prompt  recovery  after  restoration 
of  proper  food.  It  is  occasionally  difficult,  however,  to  exclude  certain 
forms  of  purpura. 

The  prognosis  is  favorable,  except  in  the  most  advanced  cases  or 
when  it  is  impossible  to  remove  the  cause.  Such  complications  as  pneu- 
monia, thrombosis,  hemorrhagic  pleurisy,  meningeal  hemorrhage,  dysen- 
tery, or  acute  nephritis  may  lead  to  a  fatal  termination. 

Treatment. — Prophylaxis  consists  in  the  supply  of  sufficient  fresh 
vegetables  and  fruits.  In  lieu  of  this  it  is  now  required  by  nearly  all 
governments  that  soldiers  and  sailors  be  provided  with  canned  fruits 
and  vegetables,  lime-juice,  lemons,  and  other  antiscorbutic  articles. 

During  the  attack,  the  patient  should  be  at  once  given  as  liberal  a 
supply  of  fruit  and  vegetables  as  his  digestion  will  tolerate.  The  juice 
of  two  or  three  lemons  or  oranges  daily,  with  meat  and  fresh  vegetables — 
potatoes,  lettuce,  water-cress,  cabbage — causes  a  rapid  cessation  of  the 
disease,  except  in  the  most  advanced  cases.  It  is  not  necessary  to  restrict 
the  diet  in  any  way,  so  long  as  the  digestion  is  not  too  feeble  to  permit 
the  ingestion  of  solid  food.  It  is  then  often  necessary  to  supply  liquid 
nourishment,  especially  milk;  and  fruit  juices  must  take  the  place  of  the 
fresh  fruit.  Bitter  tonics  and  dilute  hydrochloric  acid  are  beneficial  in 
such  cases.  Such  symptoms  as  constipation  or  diarrhea  may  call  for 
special  treatment.  The  swollen,  necrotic  gums  often  require  the  applica- 
tion of  solutions  of  silver  nitrate,  potassium  permanganate,  hydrogen 
peroxid,  or  carbolic  acid.  The  hemorrhages  must  occasionally  be  treated 
as  those  in  purpura. 

SCURVY  IN  INFANTS. 

BARLOW'S  DISEASE. 

Etiology. — The  disease  is  directly  due  to  the  feeding  of  infants  ex- 
clusively with  condensed  milk,  sterilized  milk,  or  other  artificial  foods. 
Foods  which  are  claimed  to  contain  all  the  necessary  ingredients  are, 
as  a  rule,  most  dangerous.  The  disease  is  generally  encountered  after 
the  sixth  month  and  before  the  twelfth,  rarely  so  late  as  the  fifteenth. 
Faulty  hygiene  is  perhaps  influential  in  some  cases,  and  the  disease  is 
probably  sometimes  related  to  rickets  and  syphilis. 

Morbid  Anatomy. — The  gums  are  little  or  not  at  all  inflamed  before 
dentition  has  occurred.  The  lesions  are  confined  chiefly  to  the  lower 
extremities.  Extravasations  of  blood  are  found  beneath  the  periosteum, 
sometimes  under  that  of  the  tibia  and  fibula.  Superficial  necrosis  may 
follow,  and  the  epiphyses  may  separate.  The  bones  of  the  upper  extremi- 
ties, lumbar  vertebrae,  and  orbits  have  been  found  affected.  The  joints 
are  not  usually  involved,  but  the  extravasations  around  them  give 
them  the  appearance  of  being  swollen.  Hemorrhages  may  occur  in  the 
internal  organs,  especially  the  lungs,  spleen,  kidneys,  and  intestinal 
glands.  The  blood  shows  no  characteristic  change,  but  the  red  corpus- 
cles are  generally  reduced  to  a  degree  corresponding  to  the  severity  of 
the  disease. 

Symptoms. — The  disease  develops  gradually,  the  infant  showing  in- 
creasing  peevishness  and  restlessness,   until  it  finally  gives  unmistak- 


SCURVY  IN  INFANTS  309 

able  signs  of  suffering.  Its  color  is  bad,  pale  or  ashen.  Digestive  dis- 
turbances develop,  and  the  appetite  fails  or  there  may  be  excessive 
hunger.  The  tongue  is  usually  dry  and  coated,  the  breath  fetid,  and 
diarrhea  is  generally  present.  Hematuria  is  often  observed,  but  other 
hemorrhages  are  exceptional,  except  the  extravasations  along  the  bones. 
The  characteristic  feature  of  the  disease  is  the  occurrence  of  these  sub- 
periosteal hemorrhages  over  the  long  bones,  especially  of  the  lower  ex- 
tremities. They  are  generally  symmetrical.  Pyriform  swellings  form 
around  the  diaphysis,  beginning  at  the  junction  of  the  epiphysis  and 
gradually  decreasing  toward  the  shaft.  Separation  of  the  epiphysis  is 
common,  and  a  crepitus  may  be  obtained  as  a  result.  The  swellings 
are  painful,  and  the  infant  lies  with  the  legs  drawn  up.  Motion  and 
pressure  increase  the  pain  and  induce  crying.  The  skin  over  the  prom- 
inences becomes  tense  and  glazed,  sometimes  ecchymotic.  The  shafts  of 
the  affected  bones  are  sometimes  permanently  thickened.  In  the  later 
stages  of  the  disease  the  legs  are  held  in  extension  usually  with  the 
toes  turned  outward,  and  the  condition  is  spoken  of  as  pseudoparalysis. 
Extravasations  and  edema  about  the  orbits,  often  occurring  early,  give 
the  infant  a  peculiar  appearance,  and  the  globes  may  become  unduly 
prominent  (proptosis),  on  account  of  hemorrhages  into  the  orbits.  The 
course  of  the  disease  is  usually  progressive  so  long  as  the  improper  food 
is  continued,  but  recovery  generally  follows  the  adoption  of  a  mixed  diet. 

Diagnosis.— ThQ  distinctive  features  of  the  disease  are  the  peculiar 
painful  swellings,  the  fretfulness,  edema  of  the  eyes,  and  the  position  of 
the  legs.  A  differentiation  must  frequently  be  made  between  acute  rheu- 
matism, rickets,  purpura,  and  infantile  syphilis.  Acute  rheumatism  affects 
the  joints,  and  the  swelling  does  not  follow  the  shaft  of  the  bone.  Fever 
is  a  prominent  symptom,  and  the  pain  and  tenderness  are  greater.  The 
salicylates  give  relief.  Rickets  can  generally  be  recognized  by  the  enlarge- 
ment of  the  epiphysis,  without  painful  swelling,  the  beaded  appearance 
of  the  ribs,  deformed  chest,  and  square  head.  The  abdomen  is  enlarged, 
and  digestive  disturbances  prominent.  But  scurvy  and  rickets  are  some- 
times associated.  Purpura  does  not  show  the  peculiar  subperiosteal 
extravasations  or  the  painful  swelling,  as  a  rule.  Petechiae  and  ecchy- 
moses  are  common;  the  disease  is  unusual  in  infants  and  is  of  shorter 
duration.  Syphilis  is  not  accompanied  with  the  hemorrhagic  lesions, 
but  with  others,  especially  about  the  mouth,  which  are  characteristic. 
The  pseudoparalysis  may  be  mistaken  for  true  paralysis,  but  in  the 
latter  there  is  complete  loss  of  voluntary  motion,  and  not  merely  a 
restriction  of  it  on  account  of  pain. 

Prognosis. — Recovery  is  rapid  when  the  disease  is  recognized  and 
treated  early ;  but  if  neglected,  it  may  terminate  fatally. 

Treatment. — The  artificial  food  must  be  replaced  with  properly  pre- 
pared cow's  milk  to  which  egg  albumen  and  a  teaspoonful  of  beef-juice 
should  be  added  once  or  twice  a  day.  From  a  half-ounce  to  an  ounce 
of  the  juice  of  the  orange,  lemon,  grape,  or  apple  should  be  given  to  an 
infant  during  each  24  hours.  Potatoes  and  baked  apple  may  be  given 
to  an  infant  more  than  a  year  old,  providing  its  digestion  is  not  too 
feeble.  The  sirup  of  the  iodic!  of  iron  or  minute  doses  of  arsenic  have 
been  found  of  benefit  in  overcoming  the  anemia.  The  swollen  limbs 
should  be  wrapped  in  cotton  and  protected  from  motion  and  pressure. 


3IO  PRACTICE  OF    MEDICINE 

Prophylaxis  demands  a  more  restricted  use  of  the  so-called  substitutes 
for  mother's  milk.  When  these  must  be  used,  a  food  prepared  with 
fresh  milk  and  permitting  the  addition  of  beef-juice  should  be  selected. 
Overheating  the  milk  is  also  injurious. 


STATUS  LYMPHATICUS. 

Lymphatism. 

Definition. — A  rare  affection  of  childhood  and  youth  characterized  by 
hyperplasia  of  the  lymphatic  glands  and  tissues  throughout  the  body, 
the  spleen,  thymus,  and  lymphoid  bone-marrow. 

Etiology. — The  cause  is  unknown.  The  disease  is  often  associated 
with  rickets  and  with  hypoplasia  of  the  heart  and  aorta,  and  in  quite 
a  number  of  instances  its  presence  has  been  revealed  after  sudden  death. 

Morbid  Anatomy. — All  the  lymphatic  structures  are  found  in  a  state 
of  hyperplasia,  but  most  notably  those  of  the  alimentary  canal,  in- 
cluding the  tonsils.  The  intestinal  follicles  often  stand  out  prominently 
upon  the  surface.  The  bronchial  glands  are  also  enlarged.  The  lym- 
phatic swellings  are  generally  iirm,  but  the  spleen  is  soft  and  hyperemic, 
sometimes  not  greatly  enlarged.  The  thymus  is  also  soft  and  large  and 
it  may  contain  a  large  quantity  of  a  milky  fluid.  The  bone  marrow 
often  becomes  red  and  may  undergo  hyperplasia.  The  thyroid  gland 
may  also  be  enlarged.  Lack  of  development  of  the  heart  and  aorta, 
sometimes  also  of  the  entire  arterial  system,  has  been  observed. 

Symptoms. — The  enlargement  of  the  external  glands  can  be  felt, 
that  of  the  deep-seated  glands,  particularly  those  within  the  thorax, 
may  be  determined  by  percussion;  the  spleen  is  generally  palpable. 
The  child  appears  rachitic  and  develops  slowly.  Its  vitality  and 
power  of  resistance  seem  to  be  lowered.  Sudden  death  has  occurred 
in  several  instances  under  the  administration  of  an  anesthetic,  after  a 
dose  of  diphtheria  antitoxin,  or  during  convalescence  from  an  acute 
infection.  Sudden  deaths  while  bathing  or  immediately  after  falling  into 
the  water,  as  well  as  those  from  unrecognized  causes,  have  been  attributed 
to  this  condition.  Our  knowledge  of  the  affection  is  very  incomplete,  and 
further  investigations  are  necessary. 


DISEASES  OF  THE  SUPRARENAL  BODIES. 

ADDISON'S  DISEASE. 

Definition. — A  constitutional  disease  characterized  by  asthenia,  feeble 
circulation,  gastric  irritability,  and  pigmentation  of  the  skin. 

Etiology. — The  disease  is  a  rare  one,  more  frequent  in  men  between 
20  and  40  years  of  age.  A  few  cases  have  occurred  in  infants  and  very 
old  persons.  Of  predisposing  causes,  tuberculosis  is  regarded  as  the 
most  important,  but  in  some  cases  there  has  been  a  history  of  injury,  as 
a  blow  upon  the  abdomen  or  back,  caries  of  the  vertebrae,  psoas  abscess, 
or  other  condition  of  doubtful  importance,  previous  to  the  development 
of  the  disease.  The  immediate  cause  has  not  been  fully  determined. 
Lesions  are  aljnost  constantly  found  in  the  adrenals  and  almost  as  con- 


DISEASES  OF  THE  SUPRARENAL  BODIES  311 

stantly  in  the  fibers  of  the  abdominal  sympathetic  nerves.  There  are, 
therefore,  two  principal  theories  in  regard  to  the  origin  of  the  disease : 
(i)  That  it  originates  from  an  arrest  of  the  function  of  the  adrenal 
bodies,  with  loss  to  the  system  of  their  powerful  internal  secretion,  and 
(2)  that  it  is  due,  in  part  at  least,  to  a  neuritis  of  the  abdominal 
sympathetic  fibers.  Both  theories  are  doubtless  correct,  each  in  part 
explaining  the  phenomena  of  the  condition.  The  view  that  the  symp- 
toms do  not  depend  wholly  upon  the  lesions  of  one  organ  is  supported 
by  the  imperfect  success  obtained  from  the  administration  of  adrenalin. 

Morbid  Anatomy. — The  body  is  seldom  anemic  or  markedly  emaciated. 
The  skin  is  dififusedly  pigmented,  the  mucous  membranes  and  sometimes 
the  serous  membranes  in  patches.  The  pigment  is  deposited  in  the 
lower  layer  of  the  rete  Malpighii,  where  it  is  normally  most  abundant 
in  the  negro.  The  most  important  lesions  are  found  in  the  adrenal 
bodies,  in  the  abdominal  sympathetic  nerves,  particularly  in  the  semi- 
lunar ganglia. 

The  lesions  of  the  adrenals  are :  {^a^  Most  frequently  tubercular,  the 
capsules  being  found  in  many  cases  in  an  advanced  state  of  caseation 
with  hyperplasia  of  their  connective  tissue;  (i^)  simple  atrophy,  or 
atrophy  with  sclerosis;  ((^)  carcinoma  or  sarcoma;  (^)  extravasation  of 
blood.  Both  bodies  are  usually  involved  in  these  lesions.  (<?)  The  dis- 
ease sometimes  exists  without  recognizable  alteration  of  the  adrenal 
bodies,  but  with  changes  in  the  semilunar  ganglia  or  solar  plexus,  due 
to  pressure  or  inflammation.  All  these  conditions,  however,  with  the 
exception  of  tuberculosis,  are  extremely  rare. 

The  lesions  of  the  nerve-fibers  are  generally  sclerotic  in  character, 
with  degenerative  changes  and  more  or  less  marked  pigmentation.  Com- 
pression of  the  ganglia  by  the  hyperplastic  connective  tissue  about  the 
capsules  can  sometimes  be  distinctly  demonstrated. 

Other  lesions  commonly  associated  with  those  just  described  are  en- 
largement of  the  intestinal  lymph-follicles,  enlargement  and  softening  of 
the  spleen,  and  parenchymatous  or  fatty  degeneration  of  the  heart, 
liver,  and  kidneys  in  some  cases.  The  thymus  gland  may  have  failed 
to  undergo  atrophy,  and  it  is  sometimes  slightly  enlarged. 

The  interrelation  of  these  lesions  with  reference  to  cause  and  effect 
remains  undetermined,  although  much  study  has  been  given  to  the 
subject.  While  the  importance  of  the  lesions  in  the  suprarenal  bodies 
has  become  more  apparent  since  the  action  of  their  internal  secretion 
(adrenalin)  has  been  demonstrated,  the  lesions  of  the  sympathetic  gan- 
glia and  solar  plexus  are  looked  upon  by  many  writers  as  the  direct 
cause  of  the  pigmentations,  debiUty,  and  functional  disturbances  on  the 
part  of  the  circulatory,  respiratory,  and  digestive  systems.  The  view  is 
supported  by  the  fact  that  pigmentation  of  the  skin  is  sometimes  asso- 
ciated with  tuberculosis  of  the  peritoneum,  cancer  of  the  pancreas,  and 
aneurism  of  the  abdominal  aorta.  Finally,  advanced  lesions  of  the 
adrenals  have  been  found  in  cases  in  which  the  clinical  features  of  Ad- 
dison's disease  were  absent.  These  cases  are  explained  on  the  hypoth- 
esis that  supernumerary  bodies  were  present. 

Symptoms. — The  invasion  is  generally  so  gradual  that  the  identity 
of  the  disease  is  not  at  first  apparent.  Increasing  weakness  is  usually 
the    first    manifestation,    or   the   three   principal    symptoms — weakness. 


312  PRACTICE  OF  MEDICINE 

gastrointestinal  disturbance,  and  pigmentation  of  the  skin — may  de- 
velop simultaneously.  Sometimes  the  discoloration  of  the  skin  is  the 
first  indication.  Cases  running  an  acute  course  with  all  the  symptoms 
prominent  have  been  observed. 

Pigmentation. — The  discoloration  of  the  skin  progresses  slowly,  as  a 
rule,  and  affects  most  markedly  those  regions  in  which  pigment  is  nor- 
mally most  abundant,  as  the  face,  backs  of  the  hands,  axillae,  the 
mammary  areolae,  abdomen,  groins,  the  genitals,  and  regions  where  the 
skin  has  been  compressed  or  irritated  by  apparel.  The  color  varies 
from  a  light  yellow  to  a  dark  brown,  olive,  or  black.  The  mucous 
membranes  most  affected  are  the  lips,  mouth,  conjunctiva,  and  vagina. 
The  patches  have  often  a  bluish  color.  Pigmentation  of  the  mucous 
membranes  is  not,  however,  distinctive  of  this  disease.  Small  white 
patches  (leucoderma)  are  occasionally  seen  at  different  points  and  the 
palms  and  soles  remain  unpigmented.  Points  of  deeper  pigmentation, 
resembling  moles,  are  sometimes  scattered  over  the  surface.  Pigmen- 
tation is  occasionally  absent,  however,  throughout  the  disease. 

The  gastrointestinal  symptoms  are  often  prominent,  but  they  may 
be  absent.  Loss  of  appetite,  nausea,  and  vomiting  may  set  in  early  and 
persist  at  intervals  throughout  the  disease.  Diarrhea  often  develops 
without  apparent  cause.  Late  in  the  disease  the  abdomen  sometimes 
becomes  painful  and  retracted.  Distinct  crises  of  severe  neuralgic  pain 
in  the  epigastrium  or  hypochondriac  region  are  occasionally  observed. 

Asthenia  is  one  of  the  most  distinctive  features  and  often  one  of  the 
earliest.  It  is  characterized  by  a  progressive  loss  of  physical  and  mental 
vigor,  lassitude,  and  a  constant  feeling  of  fatigue  without  exertion. 
Dyspnea  and  palpitation  or  periodical  attacks  of  extreme  cardiac  weak- 
ness are  common.  Headache,  vertigo,  and  faintness  develop  later,  and 
the  disease  may  terminate  fatally  in  an  attack  of  syncope,  or  less  com- 
monly in  convulsions  or  delirium.  Death  may  result,  however,  from  a 
gradually  deepening  asthenia.  Notwithstanding  the  pronounced  evidences 
of  weakness,  the  physical  condition  of  the  patient  often  remains  good, 
the  muscles  large  and  firm. 

Diagnosis. — The  recognition  of  Addison's  disease  depends  upon  the  as- 
sociation of  cutaneous  pigmentation  with  pronounced  asthenia  and  gastric 
irritability,  and  not  upon  any  one  feature  of  the  disease.  Error  is  most 
likely  to  arise  from  a  too  hasty  assumption  that  an  abnormal  pigmen- 
tation is  due  to  suprarenal  disease.  In  arriving  at  a  diagnosis  it  is 
necessary  to  exclude  many  conditions;  among  them,  normal  excessive 
pigmentation,  increase  due  to  pregnancy,  arteriosclerosis,  chronic  val- 
vular disease  of  the  heart,  chronic  passive  hyperemia  of  the  liver,  malig- 
nant disease  of  the  pancreas,  tubercular  peritonitis,  melanosarcoma, 
exophthalmic  goiter,  scleroderma,  and  the  pigmentation  arising  from 
pediculosis  or  the  prolonged  ingestion  of  arsenic  or  silver.  Since  the 
disease  is  tubercular  in  a  majority  of  instances,  reaction  to  the  tuber- 
culin test  may  be  obtained. 

Prognosis. — The  course  of  the  disease  is  generally  chronic,  but  a 
fatal  termination  may  be  expected  in  most  cases  within  a  year  after  its 
recognition.  Cases  have  rarely  lasted  five  or  even  ten  years,  and  a  few 
instances  of  recovery  have  been  reported.  Temporary  remissions  are 
occasionally  observed. 


DISEASES  OF  THE  SPLEEN  313 

Treatment. — The  treatment  is  chiefly  paUiative.  The  irritabihty  of 
the  stomach  may  interfere  with  the  administration  of  tonics  for  the 
rehef  of  the  asthenia.  Dilute  hydrocyanic  acid,  creosot,  cerium  oxalate, 
champagne  and  ice  may  relieve  it.  Bismuth  and  salol  are  indicated  for 
the  diarrhea.  Iron  and  arsenic  are  sometimes  of  benefit  in  anemic  cases. 
The  diet  must  be  regulated  to  suit  the  digestion  and  with  a  view  of 
avoiding  its  derangement.  The  administration  of  the  suprarenal  ex- 
tract has  been  followed  with  excellent  results  and  apparent  cure  in  some 
cases,  but  by  complete  failure  in  others,  the  result  probably  depending 
upon  differences  in  the  anatomical  lesion.  The  dried  extract  may  be 
given  in  doses  of  gr.  j  (0.06)  three  times  a  day,  or  the  fresh  gland  may 
be  administered,  raw  or  partially  cooked.  A  glycerin  extract  is  also 
employed. 

Other  Diseases  of  the  Suprarenal  Bodies.— The  adrenals  are  occasion- 
ally the  seat  of  malignant,  tubercular,  adenomatous,  or  cystic  disease, 
and  they  not  infrequently  show  cloudy  swelling  or  other  degeneration 
in  connection  with  the  acute  infectious  diseases.  The  symptoms  pro- 
duced are  not  sufficiently  distinctive  to  admit  of  diagnosis,  however, 
and  they  are  of  interest  chiefly  to  the  pathologist. 


DISEASES  OF  THE  SPLEEN. 

MOVABLE  SPLEEN. 
Floating  Spleen,  Wandering  Spleen,  Splenoptosis. 

Etiology. — Abnormal  mobility  of  the  spleen  is  usually  associated  with 
enteroptosis.  It  is  therefore  due,  for  the  most  part,  to  the  same  causes, 
namely,  a  congenital  weakness  of  attachment  and  subsequent  pressure, 
as  by  tight-lacing  or  injury,  the  dragging  of  a  tumor,  or  dilatation  of 
the  stomach. 

Symptoms. — The  displacement  is  sometimes  discovered  accidentally 
during  examination  for  other  conditions.  The  lower  border  may  be  as 
low  as  the  brim  of  the  pelvis  in  extreme  cases.  The  normal  area  of  dull- 
ness is  then  absent.  Sometimes  there  is  pain  or  a  sense  of  dragging 
in  the  splenic  region  or  in  the  side  and  back.  It  is  generally  distinguish- 
able by  its  shape.  The  ureter,  bladder,  or  bowel  may  be  compressed, 
and  the  splenic  vessels  may  be  twisted.  Fever,  pain,  and  swelling  are 
then  produced. 

Treatment. — The  organ  can  generally  be  replaced  by  taxis,  unless 
adhesions  have  formed.  An  abdominal  binder  should  then  be  worn. 
Successful  removal  of  the  dislocated  spleen  has  been  performed,  and 
Halsted  has  relieved  the  condition  by  the  formation  of  artificial  ad- 
hesions. 

RUPTURE  OF  THE  SPLEEN. 

Etiology. — Rupture  may  occur  spontaneously  or  as  a  result  of  trauma 
when  the  organ  is  intensely  hyperemic,  as  in  some  cases  of  malaria, 
typhoid  fever,  or  other  conditions  to  which  reference  has  been  made 
elsewhere. 


314  PRACTICE  OF  MEDICINE 

The  symptoms  are  those  of  internal  hemorrhage,  with  severe  pain 
and  collapse,  which  rapidly  proves  fatal  unless  promptly  submitted  to 
surgical  treatment.  Immediate  operation  offers  the  only  possible  means 
of  arresting  the  hemorrhage. 

ACUTE   SPLENITIS. 

Etiology. — No  distinct  line  can  be  drawn  between  the  intense  hyper- 
emia often  associated  with  the  acute  infectious  diseases,  and  acute  splen- 
itis. The  latter  condition  may,  however,  result  from  injury  or  as  an 
extension  of  inflammation  from  adjacent  organs.  Instances  of  peri- 
splenitis, in  which  the  capsule  alone  is  involved,  are  occasionally  met 
with. 

Symptoms. — Pain  and  tenderness  are  present,  especially  when  the  cap- 
sule is  chiefly  involved,  and  the  organ  is  more  or  less  enlarged. 

Treatment  is  seldom  directed  to  the  splenic  condition,  but  rather 
to  the  underyling  disease.  Local  applications  should  be  employed  for  the 
relief  of  pain. 

CHRONIC    SPLENITIS. 

This  affection  usually  assumes  the  form  of  a  chronic  induration. 
The  organ  is  greatly  hypertrophied,  and  the  section  shows  pigmenta- 
tion, sometimes  in  successive  layers.  A  localized  form  is  seen  also 
around  old  hemorrhagic  infarcts,  abscesses,  and  foreign  bodies. 

Symptoms. — These  are  usually  limited  to  a  feeling  of  weight  and 
oppression  due  to  the  enlargement,  or  disturbances  of  the  bowel,  or 
shortness  of  breath  as  a  result  of  upward  pressure. 

Treatment. — As  the  condition  is  generally  due  to  malaria,  syphilis, 
or  leukemia,  the  treatment  must  be  directed  to  these  conditions.  Ex- 
cision of  the  enlarged  spleen  has  been  successfully  performed. 

INFARCTION  OF  THE  SPLEEN. 

Infarction  arises  from  the  plugging  of  one  or  more  branches  of  the 
splenic  artery  by  emboli,  which  may  be  either  simple  or  infectious.  The 
former  generally  arise  from  the  vegetations  of  endocarditis  or  from  the 
interior  of  an  aneurism;  the  latter  from  malignant  endocarditis,  pyemia, 
or  other  severe  infectious  condition,  especially  typhoid  fever.  Thrombosis 
of  the  splenic  vein  is  a  possible  cause. 

The  symptoms  are  seldom  diagnostic.  The  presence  of  the  condition 
may  be  inferred,  however,  when  severe  pain  in  the  spleen  is  associated 
with  chill,  rapid  elevation  of  temperature,  vomiting,  and  enlargement 
of  the  organ. 

ABSCESS  OF  THE  SPLEEN. 

Abscess  generally  results  from  infarction,  but  it  may  arise  directly 
from  infection  by  septic  emboli,  or  rarely  from  rupture  of  a  gastric 
ulcer,  or  trauma.  The  abscess  may  be  minute,  or  so  large  as  to  convert 
the  entire  organ  into  a  pus-sac.    The  abscess   may    rupture    into    the 


DISEASES  OF  THE  THYROID  GLAND  315 

colon,  into  the  peritoneal  cavity,  or  upward  through  the  diaphragm. 
Fatal  peritonitis  follows  rupture  into  the  peritoneum.  The  treatment 
is  surgical. 

SPLENOMEGALY. 

Splenic  Anemia,   Splenic  Pseudoleukemia. 

Definition. — A  form  of  anemia  attended  with  great  enlargement  of  the 
spleen,  without  other  pathological  lesions. 

Etiology. — The  condition  is  now  looked  upon  as  an  independent  af- 
fection, but  until  recently  it  was  regarded  as  a  splenic  form  of  Hodg- 
kin's  disease.    No  definite  cause  has  been  determined. 

Morbid  Anatomy. — The  organ  is  enormously  enlarged,  smooth,  firm, 
and  deeply  notched.  The  capsule  is  adherent.  The  histological  appear- 
ances are  differently  described.  Some  writers  refer  to  sclerosis  and  at- 
rophy of  the  Malpighian  corpuscles ;  others,  notably  Bovaird,  to  a  pro- 
liferation of  endothelial  cells,  not  only  in  the  spleen,  but  in  the  liver  and 
lymphatic  glands.  The  condition  has  been  found  in  connection  with 
hepatic  cirrhosis,  tuberculosis,  typhoid  fever,  and  other  infections.  A 
varicose  condition  of  the  esophageal  veins  has  been  noted  in  some  cases, 
and  this  condition  was  doubtless  the  source  of  profuse  hematemesis  and 
melena  in  other  cases.  Ascites  may  occur  independently  of  the  condition 
of  the  liver.  The  anemia  is  usually  moderate,  the  red  corpuscles  seldom 
falling  below  3,000,000.  The  hemoglobin  is  reduced,  possibly  to  50  per 
cent,  and  the  leucocytes  may  be  normal  or  decreased.  The  evidences  of 
anemia  are  sometimes  altogether  absent. 

The  diagnosis  is  based  upon  the  large  size  of  the  spleen  and  the  ab- 
sence of  blood  conditions  characteristic  of  leukemia,  pseudoleukemia,  or 
malaria,  the  hemorrhages  of  purpura,  the  history  of  syphilis,  or  the 
bone  lesions  of  rickets. 

TUMORS  OF    THE   SPLEEN. 

Sarcoma  and  carcinoma  are  occasionally  found  in  the  spleen  as  sec- 
ondary growths,  the  former  more  frequently  than  the  latter.  Tubercles 
and  gummata  sometimes  occur.  The  local  disease  is  seldom  of  clinical 
importance,  however,  owing  to  the  greater  prominence  of  lesions  in 
other  organs. 

The  echinococcus  cyst  is  sometimes  found  and  must  be  differentiated 
from  abscess.  It  is  usually  recognized  by  its  slow  growth,  the  absence 
of  chills,  fever,  and  leucocytosis,  and  by  the  character  of  the  fluid  with- 
drawn by  aspiration.    Hooklets  may  be  found. 

Amyloid  spleen  (lardaceous,  sago,  or  waxy  spleen)  is  marked  by  enor- 
mous enlargement  in  some  cases,  but  the  condition  is  usually  evident 
from  the  presence  of  amyloid  degeneration  in  other  organs,  the  history 
of  prolonged  suppuration,  and  the  typical  appearance  of  the  patient. 

DISEASES  OF   THE    THYROID  GLAND. 

THYROIDITIS. 

Definition. — An  acute  inflammation  of  the  thyroid  gland,  often  ter- 
minating in  suppuration. 


3i6  PRACTICE  OF  MEDICINE 

Etiology. — The  aftection  generally  follows  one  of  the  acute  infectious 
diseases,  as  typhoid  fever,  rheumatism,  smallpox,  or  malaria,  or  it  may 
develop  in  a  gland  already  the  seat  of  goiter.  Traumatic  cases  are  oc- 
casionally met  with.  Thyroid  abscess  may  result  from  metastasis  or 
from  hemorrhage  into  a  goiter.  Pregnant  women  and  those  suffering 
from  suppression  of  menstruation  are  more  susceptible  to  it.  Inflamma- 
tion originating  in  a  gland  that  is  already  diseased  is  sometimes  termed 
strumitis. 

Morbid  Anatomy . — The  gland  is  enlarged  and  softened.  One  or  many 
abscesses  may  be  present,  affecting  one  lobe  or  the  entire  gland.  The 
blood-vessels  are  often  distended  with  thrombi;  hemorrhages  and  ne- 
crotic foci  are  usually  found.  The  abscesses  not  infrequently  burrow- 
along  the  larynx,  trachea,  or  esophagus,  and  they  may  perforate 
either  tube  or  cause  erosion  of  the  cartilages  and  necrosis  of  the  soft 
tissues. 

Symptoms. — There  are  the  usual  indications  of  inflammation — swell- 
ing, pain,  and  tenderness — over  one  orboth  lobes  of  the  gland.  As  sup- 
puration becomes  established,  fever  develops.  Pressure  on  the  vessels 
of  the  neck  sometimes  causes  headache,  vertigo,  and  cyanosis.  The  tra- 
chea may  be  compressed,  even  to  the  extent  of  a  fatal  strangulation. 

Diagnosis. — Perichondritis  of  the  larynx,  the  only  condition  likely 
to  cause  error,  produces  swelling  above  the  thyroid  region,  not  in  it, 
and  it  is  attended  with  greater  difficulty  in  phonation. 

Treatment. — The  treatment  is  surgical,  embracing  the  early  evacua- 
tion of  the  pus  and  drainage.  Tracheotomy  may  become  necessary 
when  the  trachea  is  compressed. 

GOITER. 
Bronchocele. 

De'^ nit  ion. — Chronic  enlargement  of  the  thyroid  gland. 

Etiology. — The  disease  occurs  either  sporadically  or  endemically.  Spo- 
radic cases  are  not  uncommon  in  many  localities  of  our  own  country, 
as  in  New  England  and  Michigan.  It  is  endemic  in  the  mountainous 
regions  of  Europe,  particularly  in  the  Alps  and  Pyrenees,  and  in  some 
parts  of  Asia,  South  America,  and  Mexico.  An  infectious  influence  is 
suggested  by  its  occasional  epidemic  prevalence  in  these  districts.  The 
disease  has  been  attributed  to  an  excess  of  lime  in  the  drinking-water 
of  certain  localities.  Women  are  more  frequently  affected  than  men  and 
usually  in  early  adult  life.  It  is  occasionally  observed  in  girls  at  the 
age  of  puberty. 

Morbid  Anatomy. — The  anatomical  lesions  correspond  more  or  less 
closely  to  the  following  classification  :  ( i )  Parenchymatous  or  hyper- 
plastic, in  which  the  gland  becomes  generally  enlarged,  the  follicles 
proliferated  and  filled  with  a  colloid  substance;  (2)  vascular,  in  which 
there  is  marked  dilatation  of  the  blood-vessels,  without  hyperplasia  of 
the  gland-tissue;  (3)  cystic,  in  which  the  normal  structure  is  replaced 
by  one  or  more  large  cysts  filled  with  colloid,  amyloid,  or  hemorrhagic 
matter  or  the  debris  of  fatty  or  other  degeneration.  (4)  To  these  may 
be  added  an  interstitial  form  in  which  the  proliferation   of  connective 


DISEASES  OF  THE  THYROID  GLAND 


317 


tissue  is  the  chief  feature.  Calcareous  infiltration  sometimes  ensues 
upon  the  other  changes,  particularly  in  the  cystic  and  interstitial 
forms. 

Symptoms. — The  enlargement  may  be  uniform  or  it  may  be  more 
or  less  limited  to  one  lobe,  especially  the  right.  In  most  cases  no  symp- 
toms are  produced  further  than  the  inconvenience  occasioned  by  the 
tumor,  which  may  remain  small,  but  often  attains  enormous  size,  es- 
pecially in  the  endemic  form.  Pulsation  is  distinctly  felt  and  a  systolic 
murmur  may  be  heard  over  the  vascular  form,  and  fluctuation  in  the 
cystic,  but  the  interstitial  is  firm  and  smooth.  Dyspnea  or  aphonia 
may  be  produced  by  compression  of  the  trachea  or  larynx  in  extreme 
cases,  and  the  gland  has  been  known  to  compress  the  veins  behind  the 
upper  margin  of  the  sternum,  causing  cerebral  anemia  and  sometimes 
convulsions.  The  tumor  generally  ascends  with  the  larynx  during 
deglutition.  The  growth  is  slow  and  painless.  Spontaneous  recovery 
sometimes  occurs,  but  sudden  death  has  been  observed  as  a  result  of 
hemorrhage,  compression  of  the  pneumogastric  nerves,  or  from  some 
undiscoverable  cause. 

Diagnosis. — Simple  goiter  is  distinguishable  from  the  exophthalmic 
by  the  absence  of  exophthalmos,  tachycardia,  tremor,  and  other  evi- 
dences of  constitutional  intoxication.  Abscess  is  excluded  by  the  ab- 
sence of  pain,  tenderness,  and  fever,  and  other  tumors  of  the  neck  by 
the  localization  in  the  gland,  its  uniform  surface,  and  the  upward  move- 
ment in  deglutition. 

The  prognosis  is  ordinarily  good  with  reference  to  life,  but  the  pos- 
sibility of  sudden  death  adds  gravity  to  the  disease. 

Treatment. — Medicinal  treatment  is  generally  unsatisfactory,  except 
in  the  most  recent  cases.  Potassium  iodid  sometimes  effects  a  reduc- 
tion of  size  in  the  interstitial  form.  Belladonna  and  ergot  are  useful 
in  the  vascular  form,  and  arsenic  promptly  arrests  the  growth  in  young 
girls,  as  a  rule.  Electrolysis  has  also  effected  a  cure  in  early  cases. 
The  eating  of  the  thymus  glands  of  sheep  has  been  reported  as  curative. 
Inunctions  of  ointments  containing  iodin,  mercuric  biniodid,  or  lead 
iodid  are  beneficial. 

« 

EXOPHTHALMIC    GOITER. 
Parry's  Disease,  Graves's  Disease,  Basedow's  Disease. 

Definition. — A  disease  the  principal  features  of  which  are  exophthal- 
mos, hypertrophy  of  the  thyroid  gland,  rapid  action  of  the  heart,  and 
tremor. 

Etiology. — The  disease  may  develop  at  any  time  of  life  and  in  either 
sex,  but  it  is  much  more  common  in  women  between  20  and  30.  A 
hereditary  influence  is  sometimes  apparent,  and  several  cases  may  occur 
in  the  same  neurotic  family.  A  form  of  the  affection  has  been  developed 
during  pregnancy,  but  pregnancy  has  no  influence  upon  the  previously 
developed  disease.  Emotional  disturbances,  as  fright  and  worry,  severe 
mental  strain,  or  an  acute  infectious  disease  has  repeatedly  preceded 
the  appearance  of  the  disease.  Many  cases  develop  without  recognizable 
exciting  cause. 


3i8  PRACTICE  OF  MEDICINE 

The  principal  theories  of  the  etiology  are  :  (t?)  That  the  disease  is 
a  pure  neurosis;  (^)  that  it  is  due  to  lesions  in  the  central  nervous 
system,  the  medulla  oblongata,  or  the  sympathetic  system;  and  (^) 
that  it  is  due  to  disease  of  the  thyroid  gland,  a  superactivity  (hyper- 
thyrea),  the  reverse  of  myxedema  (athyrea).  While  all  of  these  theories 
are  supported  in  a  measure  by  occasional  anatomical  findings,  or  by 
special  features  of  the  disease,  the  last  is  borne  out  both  by  changes 
in  the  gland  and  by  experimental  evidence  obtained  from  the  adminis- 
tration of  thyroid  extract.  This  drug  in  excessive  dose  produces  rapidity 
of  the  heart's  action,  headache,  tremor,  and  prostration  analogous  to 
those  of  the  disease.  Exophthalmos  was  observed  in  one  instance  after 
an  overdose. 

Morbid  Anatomy. — The  changes  in  the  gland  are  those  of  an  active 
hyperplasia,  with  proliferation  of  tubular  spaces  from  the  acini,  often 
accompanied  with  proliferation  of  the  epithelium  to  such  an  extent  as 
to  produce  the  appearance  of  a  villous  formation.  The  changes  are  com- 
pared by  Berkeley  to  the  involution  of  the  mammary  gland  of  a  nursing 
mother.  The  cylindrical  epithelium  is  often  fatty,  and  the  interior  of 
the  follicles  is  filled  with  a  pale  colloid  material,  supporting  the  theory 
of  a  hypersecretion.  Changes  have  been  discovered  in  the  medulla  and 
other  portions  of  the  nervous  system  in  a  few  cases.  Persistence  of  the 
thymus  gland  is  observed  in  most  instances. 

Symptoms. — The  disease  is  usually  chronic.  An  acute  form  is  occa- 
sionally met  with,  however,  in  which  the  onset  is  rapid,  and  in  a  few 
instances  a  fatal  termination  has  occurred  within  three  or  four  days. 
In  such  cases  the  heart's  action  becomes  rapid  and  the  arteries  throb 
violently,  uncontrollable  vomiting  and  diarrhea  set  in,  the  eyes  become 
prominent,  the  thyroid  gland  large,  and  in  some  cases  delirium  super- 
venes. 

In  the  chronic  form  the  invasion  is  insidious,  several  months  or  even 
years  elapsing  in  some  cases  before  the  symptoms  become  fully  de- 
veloped. The  cardinal  symptoms  are  tachycardia,  tremor,  exophthal- 
mos, and  enlargement  of  the  thyroid  gland.  They  do  not  always  appear 
in  this  order. 

•  I.  Tachycardia. — Rapidity  of  the  heart's  action  is  generally  the  earli- 
est manifestation.  The  pulse  may  not  at  first  exceed  loo,  but  after  the 
disease  has  become  fully  developed  it  often  reaches  i6o  or  i8o,  and  may 
run  higher  under  excitement.  It  is  usually  remarkably  regular.  The 
area  of  cardiac  dullness  is  increased,  especially  late,  when  there  may  be 
hypertrophy  and  dilatation,  and  the  impulse  is  strong  and  heaving. 
The  larger  arteries  throb,  and  the  expansile  pulsation  of  the  thyroid 
gland  has  been  mistaken  for  aneurism.  Capillary  pulsation  is  distinctly 
visible  through  the  finger-nails,  and  a  pulsation  may  be  transmitted  to 
the  veins  in  the  backs  of  the  hands.  A  loud  systolic  murmur  may  be 
heard  at  the  apex,  and  various  bruits  at  the  base  and  over  the  carotid 
and  femoral  arteries. 

2.  Tremor. — A  fine  involuntary,  muscular  tremor  with  about  eight 
vibrations  in  the  second  is  often  one  of  the  earliest  symptoms. 

3.  Exophthalmos. — Protrusion  of  the  eyeballs  may  precede  or  follow 
the  appearance  of  tremor.  It  may  be  unilateral.  It  is  not  always  a 
promment  manifestation,  but  it  may  be  so  extreme  that  the  globe  is 


DISEASES  OF  THE  THYROID  GLAND  319 

dislocated  from  the  orbit.  In  such  cases  the  eyes  are  occasionally  de- 
stroyed by  panophthalmitis.  It  is  generally  immediately  recognizable, 
owing  to  the  inability  of  the  lids  to  completely  cover  the  conjunctiva;. 
When  the  protrusion  is  moderate,  it  can  be  determined  in  some  cases 
by  Graefe's  sign  :  When  the  patient  suddenly  lowers  the  eyes,  the  upper 
lids  move  downward  slowly,  leaving  the  cornese  for  a  moment  exposed. 

4.  Enlargement  of  the  thyroid  is  rarely  extreme,  and  it  may  vary  to 
a  considerable  extent  from  time  to  time.  It  may  affect  both  lobes  or 
one  more  markedly  or  exclusively,  especially  the  right.  A  distinct  pulsa- 
tion and  thrill  are  generally  felt,  and  a  distinct  murmur,  sometimes 
double,  or  the  bruit  de  diable  may  be  heard  on  auscultation  over  it. 

Other  symptoms  are  usually  observed,  especially  anemia,  progressive 
emaciation,  and  weakness,  sometimes  fever.  Great  nervous  irritability 
is  not  uncommon,  and  melancholia  may  ensue.  The  patient  may  become 
neurasthenic,  despondent,  rarely  maniacal.  Paroxysms  of  uncontrollable 
temper,  with  palpitation,  dyspnea,  rapid  breathing,  and  violent  hysteri- 
cal manifestations  sometimes  occur.  Sensations  of  cold  and  heat,  profuse 
sweating,  attacks  of  urticaria  or  pruritus,  are  not  uncommon.  Limited 
patches  of  cutaneous  hyperesthesia  are  sometimes  noted.  The  skin  may 
become  pigmented  as  in  Addison's  disease,  or  areas  of  leucoderma  and 
localized  edema  may  be  observed.  The  electrical  resistance  of  the  skin 
is  diminished  (Charcot)  ;  the  expansion  of  the  chest  is  reduced  (Bryson). 
Glycosuria  and  albuminuria  often  develop,  and  true  diabetes  has  been 
observed.  The  course  of  the  disease  is  very  variable.  Spontaneous  re- 
covery or  death  may  occur  within  a  period  of  a  few  days  or  several 
months,  but  many  cases  last  for  several  years. 

Diagnosis. — ^The  disease  is  readily  recognizable  after  it  is  fully  de- 
veloped, but  obscure  cases  are  sometimes  encountered,  as  when  the  symp- 
toms on  the  part  of  the  stomach  predominate,  and  before  thyroid  en- 
largement and  exophthalmos  have  developed.  Tachycardia  and  arterial 
and  capillary  throbbing  can  generally  be  found  on  examination. 

Treatment. — The  most  essential  part  of  the  treatment  in  most  cases  is 
a  complete  change  of  environment  and  in  the  mode  of  life.  The  earlier 
these  can  be  accomplished,  the  greater  is  the  possibility  of  recovery. 
Rest  of  body  and  mind  is  essential;  all  worry  and  excitement  must  be 
removed.  In  severe  cases  it  is  better  to  confine  the  patient  to  bed  for  a 
time,  especially  after  an  acute  exacerbation.  An  ice-bag  often  quiets  the 
action  of  the  heart.  It  should  be  worn  constantly,  over  the  heart  or 
over  the  manubrium  sterni  and  lower  part  of  the  neck,  as  advised  by 
Osier.  Prolonged  galvanization,  with  the  anode  over  the  cervical  spine 
and  the  cathode  over  the  peripheral  nerves,  has  proved  beneficial.  Drugs 
are  for  the  most  part  unreliable,  but  in  conjunction  with  rest  they  are 
often  of  great  service.  Aconite  in  full  doses  is  of  great  benefit  in  some 
cases,  and  its  action  is  aided  by  large  doses  of  the  bromids,  3  ij  (7-7°) 
being  given  in  a  day.  Musser  has  found  small  doses  of  opium  curative. 
Digitalis  quiets  the  heart's  action  and  reduces  the  thyroid  in  some  in- 
stances. Belladonna,  strophanthus,  and  veratrum  viride  have  been  em- 
ployed with  apparent  benefit  by  some  writers,  but  they  cannot  be  de- 
pended upon,  and  prove  injurious  in  some  cases.  Arsenic  and  iron  are 
indicated  for  the  anemia.  Thyroid  extract  is  harmful  and  may  produce 
alarming  symptoms.    Surgical  treatment,  embracing  the  removal  of  one 


320  PRACTICE  OF  MEDICINE 

lobe,  and  other  methods  have  been  tried,  but  there  is  great  danger  of 
death  from  the  anesthesia.  Division  of  the  cords  of  the  cervical  sympa- 
thetic has  recently  proved  successful. 

MYXEDEMA. 
Athyrea. 

Definition. — A  disorder  of  nutrition  due  to  atrophy  and  arrest  of  the 
function  of  the  thyroid  gland,  and  characterized  by  myxomatous  in- 
filtration of  the  subcutaneous  tissues,  with  dry  desquamation  of  the  skin 
.and  mental  failure.  Three  forms  of  the  disease  are  recognized:  (i) 
Myxedema  proper,  (2)  cretinism,  and  (3)  operative  myxedema  (cachex- 
ia strumipriva). 

Etiology. — Cretinism  may  be  a  congenital  condition,  or  it  may  develop 
at  any  time  before  puberty.  It  is  due  to  the  absence  or  loss  of  the  func- 
tion of  the  thyroid  gland.  The  causes  of  this  functional  arrest  are  not 
usually  recognizable,  but  in  one  instance  at  least  it  followed  destruction 
of  the  gland  by  actinomycosis.  The  gland  is  sometimes  congenitally 
absent,  and  it  may  undergo  atrophy  after  one  of  the  acute  infectious 
diseases.  A  transitory  form  of  the  affection  has  followed  exophthalmic 
goiter.  Women  are  more  frequently  affected;  hereditary  transmission 
through  the  mother  has  been  observed,  and  several  cases  not  infrequently 
occur  in  the  same  family.  The  disease  is  much  less  common  in  this  coun- 
try than  in  some  districts  of  Europe. 

Symptoms. — Myxedema. — The  chief  manifestations  of  true  myxedema 
.are  seen  in  the  integument  and  in  the  nervous  system.  Owing  to  the 
infiltration  of  the  subcutaneous  tissues,  the  facial  expression  is  lost; 
the  face  appears  broad  and  expressionless.  Flattened,  tumor-like  masses 
sometimes  form  on  the  sides  of  the  head  and  elsewhere.  The  face  has 
usually  an  edematous  appearance,  a  puffiness  like  that  of  acute  nephri- 
tis. The  lips  and  alee  of  the  nose  are  much  thickened.  The  skin  of  the 
entire  body  becomes  similarly  affected,  the  surface  dry  and  scaly.  The 
hair  is  more  or  less  completely  lost  from  all  parts  of  the  body.  The  bony 
frame  is  not  enlarged,  as  it  is  in  acromegaly,  but  the  soft  parts  are  much 
increased.  The  hands  and  feet  are  broad.  Large  accumulations  are  often 
found  in  the  supraclavicular  regions.  The  movements  of  the  body  are 
slow,  and  the  action  of  the  mind  is  equally  sluggish.  The  speech  is  slow 
and  drawling.  Headache  often  develops,  and  the  patient  becomes  ir- 
ritable. In  severe  cases  delusions  and  hallucinations  appear,  and  they 
may  lead  to  a  fatal  dementia.  The  functions  of  the  vital  organs  are 
generally  unaffected,  but  glycosuria  is  not  uncommon,  and  albuminuria 
sometimes  develops.  The  temperature  is  normal  or  subnormal;  the  sur- 
face temperature  is  low.  Death  is  usually  a  result  of  tuberculosis  or 
other  intercurrent  malady.  The  disease  may  last  ten  or  fifteen  years, 
but  an  early  fatal  termination  has  been  repeatedly  noted. 

Cretinism.— T)i^  endemic  form  is  usually  congenital;  the  sporadic  form 
appears  after  the  first  year,  as  a  rule.  They  are  the  same  in  nature. 
With  the  appearance  of  the  disease,  the  development  of  the  child  is  ar- 
rested, and  the  infantile  appearance  is  often  retained  for  many  years. 
The  growth  of  the  body  is  very  slow.  The  expression  is  heavy,  owing 
to  the  thickening  of  the  subcutaneous  layer,  as  in  true  myxedema.    The 


DISEASES  OF  THE  THYMUS  GLAND  321 

body  is  often  much  deformed  by  the  excessive  enlargement  of  certain  re- 
gions. The  face  is  extremely  puffy,  so  that  it  is  large  in  comparison  to 
other  parts  of  the  body.  The  tongue  is  thick  and  hangs  out  of  the  mouth. 
The  legs  remain  short  and  become  thick  and  stocky ;  the  hands  and  feet 
are  poorly  developed.  The  face  is  pale  and  waxy ;  the  fontanels  remain 
open.  The  muscles  are  so  weak  that  the  child  cannot  sit  or  stand.  The 
intellect  remains  undeveloped;  the  child  is  an  idiot  when  the  condition 
is  congenital,  or  an  imbecile  when  it  appears  later.  Congenital  cases 
are  rare,  and  generally  terminate  fatally  within  the  first  two  years. 

Operative  myxedema  develops,  as  a  rule,  only  after  total  extirpation 
of  the  thyroid  gland,  and  not  then  in  case  supernumerary  glands  should 
be  present.  But  in  a  few  instances  it  has  developed  after  partial  removal. 
Comparatively  few  cases  of  this  character  have  been  observed  in  man. 

Diagnosis. — The  pallor  and  puffiness  of  the  face  may  be  mistaken  for 
the  edema  of  parenchymatous  nephritis,  and  the  diagnosis  is  often  sup- 
ported by  the  presence  of  albumin  and  casts  in  the  urine.  But  the  puffy 
swellings  do  not  pit,  as  in  edema;  and  the  dryness  and  scaliness  of  the 
skin,  the  ragged  alopecia,  and  the  dullness  of  the  intellect  usually  re- 
move all  doubt. 

Treatment. — The  thyroid  extract  or  the  powdered  gland  of  the  sheep 
is  a  specific  remedy.  It  should  be  given  in  small  doses  at  the  start,  but 
rapidly  increased  until  gr.  v  to  x  (0.30 — 0.60)  are  given  three  times  a  day. 
Children  can  take  half  the  adult  dose,  as  a  rule.  The  remedy  must 
not  be  discontinued  too  soon.  Its  action  is  generally  rapid  and  astonish- 
ing, but  relapse  follows  its  discontinuance  in  most  cases.  Some  patients 
find  it  necessary  to  take  an  occasional  dose  during  the  remainder  of  life. 

Tumors  of  the  Thyroid  Gland.— Adenomata,  fibromata,  cysts,  and 
malignant  growths  are  occasionally  met  with.  The  lesions  of  tubercu- 
losis, syphilis,  actinomycosis,  and  hydatids  are  sometimes  found. 


DISEASES  OF  THE  THYMUS  GLAND. 

The  thymus  gland  normally  shrinks  to  a  small,  probably  function- 
less  remnant  between  the  fifteenth  and  twentieth  years.  Comparatively 
little  positive  knowledge  exists  regarding  the  gland  and  its  diseases. 
It  is  occasionally  found  enlarged  after  sudden  death  or  after  various 
diseases,  but  the  relation  of  the  morbid  condition  to  the  fatal  issue  is 
largely  a  matter  of  theory.  Pressure  of  the  enlarged  gland  upon  the 
trachea  is  undoubtedly  an  occasional  cause  of  asthma  in  children  (asth- 
ma thymicum)  and  of  laryngismus  stridulus,  by  some  authors  regarded 
as  identical,  but  it  is  by  no  means  the  only  cause  of  these  conditions. 
The  sudden  death  of  infants  must  sometimes  be  attributed  to  thymus 
enlargement.  In  some  cases  the  pressure  is  probably  exerted,  not  upon 
the  trachea,  but  upon  the  blood-vessels  or  the  pneumogastric  nerve. 
The  sudden  death  of  adults  while  bathing  or  during  anesthesia  is  be- 
lieved, in  some  instances,  to  be  due  to  this  cause.  The  persistence  of  the 
thymus  gland  in  exophthalmic  goiter  is  a  fact  not  yet  fully  understood. 
The  gland  has  been  found  enlarged  also  in  some  cases  o£  epilepsy. 

Abscesses  and  various  malignant  and  benign  tumors  are  occasionally 
found  in  the  thymus  gland. 


SECTION   IV. 
Diseases  of  the  Circulatory  System  and  Mediastinum. 


DISEASES  OF  THE  PERICARDIUM. 

PERICARDITIS. 

Def/nifion. — Inflammation  of  the  pericardium,  arising  from  infection, 
trauma,  or  extension  from  diseases  in  adjacent  structures.  The  disease 
is  to  be  studied  under  the  following  heads:  (i)  Acute  plastic  or  "dry" 
pericarditis,  (2)  pericarditis  with  serous  effusion,  (3)  pericarditis  with 
purulent  or  hemorrhagic  effusion,  (4)  chronic  adhesive  pericarditis,  (5) 
tubercular  pericarditis,  and  (6)  cancerous  pericarditis. 

I.  Acute  Plastic  Pericarditis.  2.  Pericarditis  with  Serous  Effu- 
sion.— Etiology. — The  causes  of  these  two  forms  are  practically  the 
same  and  may  be  advantageously  considered  together.  The  disease 
occurs  at  all  periods  of  life,  corresponding  in  a  measure  to  the  preva- 
lence of  the  affections  to  which  it  bears  a  secondary  relation.  It  is 
more  frequent,  however,  in  males.  It  assumes  epidemic  proportions 
only  when  it  is  associated  with  a  widespread  epidemic  of  an  infectious 
disease,  notably  influenza  or  pneumonia. 

(«)  Primary  Pericarditis. — Cases  of  so-called  idiopathic  or  primary 
pericarditis  are  extremely  few.  They  are  generally  met  with  in  children 
in  whom  no  evidence  of  previous  local  or  constitutional  illness  has  been 
recognized.  It  is  quite  probable,  however,  that  many  cases  regarded 
as  primary  are  in  reality  secondary  to  an  unrecognized  mild  type  of 
infection,  or  that  they  are  tubercular  in  character. 

(/^)  Secondary  Pericarditis. — As  a  secondary  affection,  acute  pericar- 
ditis occurs  most  frequently  in  the  young  and  middle-aged,  (i)  Fully 
half  the  cases  follow  acute  rheumatism,  or  they  are  associated  with  the 
acute  tonsilitis  of  rheumatic  subjects.  The  pericardial  inflammation 
sometimes  precedes  the  articular.  (2)  Less  frequently,  it  follows  other 
acute  infections,  particularly  influenza,  scarlet  fever,  or  pneumonia.  (3) 
It  is  not  unusual  after  acute  septic  processes,  as  septicemia,  pyemia, 
puerperal  sepsis,  malignant  endocarditis,  necrosis  of  bone,  and  it  is  not 
infrequently  met  with  in  the  new-born  infant  as  a  result  of  septic  infec- 
tion through  the  navel.  (4)  In  altered  blood-states,  especially  gout 
and  chronic  interstitial  nephritis,  affecting,  as  a  rule,  individuals  past 
50  years  of  age,  sometimes  also  in  scurvy  and  diabetes.  (5)  It  is  often 
tubercular  in  character,  occurring  primarily  in  the  general  involvement 
of  serous  membranes  or  as  a  result  of  extension  from  the  lungs  or 
lymph-glands. , 

(r)  As  a  result  of  direct  extension  of  inflammation  the  disease  is  met 
with  in  pleuropneumonia,   especially  in  children  and   alcoholic   adults, 


DISEASES  OF  THE   PERICARDIUM  323 

rarely  in  connection  with  simple  pleurisy,  but  occasionally  in  suppurative 
myocarditis  and  aneurism  of  the  aorta. 

Morbid  Anatomy.— The  morbid  process  may  be  confined  to  a  limited 
area  or  it  may  be  general.  In  the  beginning  of  the  plastic  form,  the 
affected  surface  is  inflamed  and  opaque,  but  smooth,  A  plastic  exu- 
date of  variable  thickness  is  soon  thrown  out,  which  gives  it  a  rough- 
ened surface.  When  the  plastic  matter  is  abundant  it  is  given  a  peculiar 
appearance  by  the  movements  of  the  heart.  It  is  often  compared  to  the 
shredded  appearance  of  two  buttered  surfaces  that  have  been  forcibly 
separated;  it  is  sometimes  honeycombed  or  there  may  be  long  villous 
threads  (the  hairy  heart  of  the  ancients).  There  is  usually  a  slight 
increase  of  the  pericardial  fluid  and  it  may  be  clear  or  flocculent. 

Pericarditis  begins  as  a  plastic  inflammation  with  fibrinous  exudate, 
usually  most  marked  on  the  visceral  layer  about  the  base  of  the  heart, 
near  the  origin  of  the  great  vessels.  The  quantity  of  serum  that  is 
poured  out  varies  within  wide  limits,  usually  from  2  to  10  ounces 
(64.0  to  320.0),  but  sometimes  exceeds  3  pints  (1.5  liters).  The  fluid  is 
sometimes  slightly  cloudy  from  fibrin,  desquamated  epithelium,  granular 
detritus,  or  pus-corpuscles,  and  a  few  blood-cells  may  be  found  in  it.  As 
the  disease  subsides,  the  fluid  becomes  less  and  the  fibrinous  exudate 
undergoes  organization,  forming  adhesions  between  the  two  layers  of 
the  pericardium.  The  myocardium  is  usually  edematous  and  in  some 
cases  the  inflammation  extends  to  a  variable  depth  into  the  muscular 
structure.  The  acute  process  sometimes  passes  into  a  chronic  one  with- 
out complete  absorption  of  the  serum. 

Symptoms. — i.  Adhesive  Pericarditis.  —  Many  mild  cases  of  this  type 
are  overlooked  on  account  of  the  absence  of  distinctive  symptoms.  It 
is  only  in  severe  cases  that  the  subjective  manifestations  are  sufficiently 
prominent  to  attract  attention  to  the  condition.  The  most  important 
features  of  these  cases  are :  (ji)  A  sense  of  discomfort  or  constriction 
in  the  precordial  region.  Distinct  pain  is  unusual,  yet  it  is  occasionally 
so  severe  as  to  resemble  angina  pectoris.  It  may  be  felt  in  the  region 
of  the  heart  or  it  may  be  referred  to  that  of  the  xiphoid  cartilage. 
(/<)  Palpitation  with  increased  frequency  and  force  of  the  heart's  action 
are  common  in  the  early  history  of  the  disease,  but  after  adhesions 
have  formed  or  the  myocardium  has  become  affected  the  heart's  action 
usually  becomes  weak.  (<r)  Dyspnea  is  sometimes  present.  (^)  Fever 
is  generally  observed,  but  in  most  cases  it  is  a  feature  of  the  underlying 
infection. 

2.  Pericarditis  with  Serous  Effusion. — Symptoms  are  often  wanting 
also  in  the  beginning  of  this  form,  but  precordial  pain  or  distress  is 
more  common  than  in  the  simple  adhesive  form.  When,  as  rarely  hap- 
pens, the  disease  develops  as  a  primary  affection,  there  may  be  an  in- 
itial chill  with  fever  and  acceleration  of  the  heart  and  respiration;  but 
when  it  is  a  secondary  affection,  these  manifestations  are  obscured  by 
the  pre-existing  disease.  The  fever  is  seldom  high  and  it  runs  an  irregu- 
lar or  intermittent  course.  Dyspnea  develops  with  the  formation  of  the 
effusion  and  constitutes  one  of  the  most  significant  symptoms  of  the  con- 
dition. The  patient  lies  on  his  left  side,  or  he  may  be  compelled  to  sit  up 
in  bed  (orthopnea).  The  pulse  becomes  small  as  well  as  rapid,  and  ir- 
regular ;  or  it  may  present  the  features  of  the  pulsus  paradoxus,  becoming 


324  PRACTICE  OF  MEDICINE 

extremely  weak  or  imperceptible  during-  inspiration.  The  embarrassment 
of  the  heart's  action  corresponds  to  the  quantity  of  fluid  present  and  the 
consequent  pressure  that  must  be  overcome  by  the  heart  muscle  in  dias- 
tole. Other  pressure  symptoms  are  usually  observed,  as  cough  due  to 
compression  of  the  trachea,  aphonia  from  compression  of  the  recurrent 
laryngeal  nerve,  dysphagia  from  pressure  on  the  esophagus,  and  disten- 
tion of  the  veins  of  the  neck.  Nausea  and  vomiting  may  occur.  The 
dyspnea  is  probably  in  part  a  result  of  pressure  upon  the  left  lung, 
especially  when  the  pericardial  effusion  is  excessive.  The  lips  and  finger- 
nails are  blue;  cyanosis  is  often  extreme.  Such  nervous  symptoms  as 
headache,  restlessness,  and  insomnia  are  common,  and  in  the  later  stages 
there  may  be  mild  delirium  passing  into  stupor  or  coma.  Melancholia 
with  suicidal  tendency  has  been  noted  in  some  cases.  A  type  of  delirium 
resembling  that  of  alcoholism  has  been  noted,  even  in  cases  that  sub- 
sequently recovered.  Chorea  sometimes  develops  and  epileptic  seizures 
have  been  observed  during  paracentesis. 

Physf'ca/ Signs. — ( i )  Adhesive  Pericarditis. — Inspection  is  usually  negative. 
On  palpation  a  friction  fremitus  caused  by  the  rubbing  of  the  roughened 
surfaces  may  often  be  felt,  especially  over  the  right  ventricle,  but  it  is 
often  absent,  even  when  the  friction  sound  is   distinctly  heard. 

Auscultation. — A  double,  to-and-fro  friction  sound  is  the  most  dis- 
tinctive sign  of  acute  pericarditis.  Although  it  corresponds  to  the  sys- 
tolic and  diastolic  movements  of  the  heart,  the  friction  sound  is  usually 
slightly  longer  in  duration  than  these  sounds.  A  single  friction  sound 
is  sometimes  heard,  and  in  some  instances  it  has  a  distinctly  triple 
character.  The  sound  is  dryer,  harsher,  and  more  grating  or  crackling 
than  the  endocardial  murmur,  and,  like  the  pleural  friction,  it  is  often 
compared  to  the  creaking  of  new  leather.  But  it  is  sometimes  soft  and 
difficult  of  distinction.  It  is  best  heard,  as  a  rule,  at  the  left  border  of 
the  sternum,  in  the  fourth  and  fifth  interspaces.  Sometimes  it  can  be 
heard  over  the  apex  or  base,  but  it  is  not  transmitted  along  the  blood- 
vessels. One  of  the  most  characteristic  features  is  the  inconstancy  of 
the  sound  from  day  to  day.  It  may  be  heard  at  one  examination  and 
not  at  the  next. 

(2)  Pericarditis  ivith  Effusion. — Inspection. — In  children  the  precordial 
region  often  bulges  when  the  effusion  is  large,  and  the  left  side  of  the 
chest  may  appear  slightly  enlarged,  but  the  expansion  is  often  markedly 
diminished.  The  apex  beat  cannot  be  seen.  The  diaphragm  and  the 
left  lobe  of  the  liver  are  often  depressed  and  the  epigastrium  becomes 
prominent.  The  skin  of  the  precordium  sometimes  becomes  edematous. 
The  integument  and  mucous  membranes  are  pale  and  more  or  less 
cyanotic ;  the  veins  of  the  neck  are  distended  and  often  show  undulatory 
movements  or  distinct  pulsation.  The  expression  is  anxious.  The  respir- 
atory movements  are  rapid  and  often  irregular. 

Palpation.— T\it  apex  beat,  when  it  can  be  recognized,  is  displaced 
upward  and  to  the  left,  but  exceptions  to  the  rule  are  noted.  When  the 
effusion  is  abundant  the  impulse  becomes  imperceptible,  and  the  car- 
diac shock  is  lost.  Sometimes  these  impulses  can  be  restored  by  having 
the  patient  lie  on  the  left  side  or  by  inclining  the  body  forward.  The 
friction  fremitus  is  generally  lost,  but  it  may  be  present  at  the  base  in 
large  effusions.    The  impulse  is  sometimes  retained  when  the  heart  is 


DISEASES  OF  THE  PERICARDIUM  325 

hypertrophied  or  bound  to  the  chest-wall  by  old  adhesions.     Fluctuation 
can  very  rarely  or  never  be  recognized. 

Percussion  is  negative  in  adhesive  pericarditis,  but  when  effusion  is 
present  the  area  of  dullness  is  greatly  increased.  This  dull  (flat)  area 
has  a  characteristic  outline  with  the  patient  in  a  sitting  posture,  being 
irregularly  triangular  with  the  base  downward.  This  is  one  of  the  most 
positive  signs  of  the  condition.  The  normal  resonance  in  the  right 
fifth  intercostal  space,  the  so-called  cardiohepatic  angle,  is  also  obliter- 
ated. An  area  of  dullness  is  sometimes  found  also  in  the  left  infra- 
scapular  region.  A  dull  tympanitic  note  is  elicited  over  the  portion  of 
the  left  lung  that  is  compressed. 

Auscultation. — The  friction  sound  sometimes  persists,  especially  at 
the  base,  occasionally  in  a  limited  area  about  the  apex;  but  it  disap- 
pears, as  a  rule,  when  the  effusion  has  become  copious.  Later,  when 
the  fluid  undergoes  absorption,  the  sound  returns  for  a  time.  The 
heart-sounds  become  indistinct  and  distant  with  the  increase  of  effusion, 
but  the  second  sound  may  persist  at  the  base.  The  respiratory  murmur 
over  the  anterolateral  region  of  the  left  lung,  the  part  compressed  by 
the  distended  pericardium,  becomes  bronchovesicular  in  quality.  This 
area  changes,  however,  when  the  patient  assumes  a  different  posture. 

The  course  of  the  disease  corresponds  to  the  pathological  condition, 
representing  the  three  stages  of  dryness,  effusion,  and  absorption. 
The  duration  of  each  is  exceedingly  variable  in  different  cases,  depending 
largely  upon  the  cause  of  the  affection.  The  disease  sometimes  runs  a 
rapid  course.  The  effusion  may  reach  its  height  within  two  or  three 
days,  and  undergo  complete  absorption  within  an  almost  equally  short 
time.  But  it  not  infrequently  progresses  slowly  through  each  stage,  ex- 
hibiting the  features  of  a  chronic  condition;  in  some  acute  cases,  too, 
the  absorption  of  the  fluid  is  slow  and  the  disease  may  become  chronic 
or  a  purulent  pericarditis  may  be  set  up.  Adhesions  always  remain 
after  recovery  that  is  complete  in  other  respects.  When  associated  with 
rheumatism  the  disease  seldom  lasts  more  than  two  weeks.  With  the 
absorption  of  the  effusion  the  other  symptoms  gradually  disappear. 
The  temperature  falls  by  lysis,  the  dyspnea  subsides,  and  the  pulse  be- 
comes slow,  full,  and  regular.  If,  on  the  other  hand,  the  disease  pursues 
an  unfavorable  course,  the  temperature  generally  rises,  the  dyspnea  be- 
comes extreme,  the  patient  becomes  restless,  delirious,  and  finally  coma- 
tose. When  the  associated  myocarditis  is  extensive,  death  sometimes 
occurs  rather  suddenly  in  syncope. 

3.  Purulent  Pericarditis  (Empyema  of  the  Pericardium).— This  may 
follow  a  serofibrinous  pericarditis  of  variable  duration,  or  the  exudate 
may  have  a  purulent  character  from  the  beginning.  This  is  true  espe- 
cially of  tuberculous  and  septic  cases  and  occasionally  of  cases  due  to 
the  acute  infections.  Various  micro-organisms  have  been  found  in  the 
exudate,  but  for  the  most  part  those  ordinarily  associated  with  septic 
or  tuberculous  processes — the  streptococcus,  staphylococcus,  pneumo- 
coccus,  and  the  bacillus  tuberculosis. 

Morbid  Anatomy. — The  pericardium  is  greatly  thickened  and  covered 
with  a  thick  layer  of  fibrinous  exudate,  as  in  the  adhesive  form.  But 
in  addition  to  this,  the  membrane  is  infiltrated  with  fibrin  and  pus.  Its 
surface  is  opaque,  granular,  and  often  necrotic  in  patches.    A  myocar- 


326  PRACTICE  OF  MEDICINE 

ditis  is  usually  present,  or  a  fatty  degeneration  of  the  myocardium  may 
be  found.  The  quantity  of  pus  varies  from  a  few  ounces  to  four  pints 
(2  liters).  Absorption  of  the  fluid  sometimes  occurs,  leaving  a  portion 
of  the  pus  as  a  caseous  mass.  Subsequent  calcification  of  the  pericar- 
dium may  occur. 

Symptoms. — The  clinical  manifestations  are  much  the  same  as  those 
of  pericarditis  with  serous  effusion,  but  an  initial  rigor  is  more  common 
and  the  chill  is  often  repeated.  The  temperature  runs  a  course  indicative 
of  suppuration,  and  the  prostration  is  more  profound.  The  disease 
progresses  rapidly  and  almost  always  terminates  fatally. 

Hemorrhagic  Pericarditis.— The  serous  effusion  of  a  nonpurulent 
pericarditis  is  sometimes  more  or  less  distinctly  tinged  with  blood, 
especially  in  cases  associated  with  chronic  nephritis  and  those  occurring 
in  extremely  old  persons.  A  typical  hemorrhagic  pericarditis  is  gen- 
erally associated  with  the  purulent  form  of  the  disease,  and  more  partic- 
ularly when  this  is  due  to  tuberculosis. 

Diagnosis  of  Pericarditis.— The  frequency  with  which  pericarditis  is 
revealed  upon  the  post-mortem  table  in  cases  in  which  it  had  not  been 
suspected  indicates  the  importance  of  daily  examinations  of  the  heart 
during  the  course  of  the  acute  infections,  particularly  rheumatism.  A 
complaint  of  precordial  distress  or  of  dyspnea,  or  an  increase  of  fever 
without  aggravation  of  the  articular  inflammation  during  the  course 
of  rheumatism  should  arouse  suspicion  of  the  disease.  The  diagnostic 
sign  of  a  pericarditis  is  a  friction  sound.  This  may,  however,  disappear 
after  the  development  of  effusion.  Pericarditis  with  effusion  is  readily 
recognized  in  most  cases,  providing  the  heart  has  been  previously  ex- 
amined, but  in  other  cases  it  is  sometimes  determined  with  great  dif- 
ficulty. The  chief  source  of  confusion  usually  lies  in  the  exclusion  of  a 
cardiac  dilatation;  but  in  this  there  is  generally  a  history  of  chronic 
valvular  disease,  and  fever,  pain,  and  nervous  manifestations  are  absent. 
The  apex  beat  and  cardiac  impulse  are  present,  often  wavy  in  character 
and  forcible.  The  area  of  dullness  is  not  triangular  and  it  does  not 
extend  so  high  along  the  left  margin  of  the  sternum,  except  in  mitral 
stenosis,  or  so  low  in  the  fifth  and  sixth  intercostal  spaces,  and  it  does 
not  change  with  the  position  of  the  patient.  There  is  no  dull  tympany, 
as  in  pericarditis,  except,  perhaps,  in  the  most  extreme  cases  of  dilatation. 
The  first  sound  of  the  heart  is  not  lost,  and  instead  of  the  friction 
sound  one  hears  an  endocardial  murmur. 

Pleuritic  Effusion.— k  pericardial  effusion  is  probably  oftener  mistaken 
for  a  pleuritic  than  the  reverse,  in  cases  of  excessive  accumulation. 
The  absence  or  feebleness  of  the  heart  sounds  and  the  dull  tympanitic 
note  in  thie  infrascapular  region  are  the  most  distinctive  features  of  the 
pericardial  effusion,  when  the  friction  sound  is  absent;  but  an  encysted 
pleuritic  effusion  in  the  anterolateral  region  of  the  chest  is  next  to 
impossible  of  differentiation  in  some  cases. 

The  distinction  between  a  serous  and  a  purulent  effusion  cannot 
always  be  determined  without  aspiration,  a  measure  that  is  resorted 
to  only  when  it  is  required  by  the  condition  of  the  patient.  The 
character  of  the  effusion  may  be  inferred,  however,  from  the  asso- 
ciated disease.  Effusion  of  rheumatic  origin  is  generally  serous,  that  of 
tuberculosis  of  septic  disease  is  often  purulent.     Chills,  fever,  and  sweat- 


DISEASES  OF  THE  PERICARDIUM  327 

ing  supervening  upon  an  efifusion  of  considerable  duration   point  to  the 
presence  of  pus. 

Prognosis. — Simple  adhesive  pericarditis  and  pericarditis  with  serous 
effusion  are  generally  followed  by  recovery,  especially  in  rheumatic  cases, 
but  a  purulent  effusion  is  almost  always  fatal.  Good  results  have  fol- 
lowed surgical  treatment  of  purulent  effusion,  however,  in  nearly  50  per 
cent  of  recent  cases.  When  septic  infection  manifests  itself,  a  fatal  issue 
may  be  expected.  Recovery  rarely  occurs  in  the  tuberculous  form  of  the 
disease. 

Treatment.— From  the  very  beginning  the  patient  should  be  confined 
to  bed  and  given  absolute  rest,  physically  and  mentally.  All  excitement, 
especiall}^  that  occasioned  by  visitors,  should  be  guarded  against.  The 
object  of  quiet  is  to  lessen  the  heart's  action  and  thus  prevent  one  of 
the  most  potent  factors  in  the  production  of  effusion.  Drugs  are  of 
doubtful  utility  except  when  the  pain  is  so  excessive  as  to  call  for  the 
administration  of  morphin.  There  is  seldom,  if  ever,  any  indication  for 
the  use  of  digitalis,  except  for  its  diuretic  action  after  the  effusion  has 
become  profuse.  Aconite  is  serviceable  for  quieting  the  heart,  but  it  is 
not  devoid  of  danger  when  the  myocardium  has  become  involved.  Local 
applications  are  sometimes  of  great  benefit;  either  the  local  abstraction 
of  blood  by  cupping  or  leeches  in  robust  individuals,  as  favored  by 
Osier,  or  repeated  blisters,  as  recommended  by  Pepper.  Hot  and  cold 
applications  are  also  useful.  The  ice-bag  often  affords  relief  from  pain 
and  quiets  the  heart's  action.  Leiter's  coil  or  simple  compresses  may 
be  substituted  for  it.  Blisters  are  efficient,  especially  for  promoting  the 
absorption  of  fluid.  In  robust  patients  purgation  by  the  administration 
of  salts  in  concentrated  solution  is  beneficial,  but  it  should  not  be  re- 
sorted to  in  asthenic  cases.  The  action  of  the  kidneys  should  be  favored 
by  the  administration  of  potassium  bitartrate  or  acetate  or  calomel  and 
the  infusion  of  digitalis.  Potassium  iodid  is  often  of  great  service  in 
effusion.  It  should  be  given  in  small  doses  at  first  and  increased  daily 
until  gr.  x  (0.60)  t.  i.  d.  are  taken.  As  soon  as  the  effusion  becomes 
so  extensive  as  to  cause  serious  dyspnea  or  other  pronounced  pressure 
symptoms,  the  fluid  should  be  withdrawn  either  by  aspiration  or  an 
incision^  Aspiration  is  usually  sufficient  in  serous  effusion,  but  free 
incision  and  drainage  are  required  when  it  is  purulent.  The  puncture 
is  usually  made  in  the  fourth  intercostal  space,  near  the  left  margin  of 
the  sternum,  or  an  inch  (2.5  mm.)  from  it;  or  in  the  fifth  interspace, 
an  inch  and  a  half  (4  mm.)  from  the  sternum.  The  operation  must  be 
done  under  the  strictest  antisepsis  and  preferably  by  a  skilled  surgeon. 

The  diet  of  the  patient  should  be  wholly  liquid  during  the  prevalence 
of  fever,  and  later  it  should  be  light  and  nutritious  as  in  the  conva- 
lescence from  a  febrile  disease.  Tonics  are  also  indicated,  especially 
strychin  and  arsenic  or  iron,  to  strengthen  the  heart  and  improve  the 
condition  of  the  blood.  The  patient  should  be  cautioned  against  undue 
excitement  and  fatigue  until  convalescence  has  been  fully  established. 

4.  Chronic  Adhesive  Pericarditis  (Adherent  Fericardmm). —Et/o/ogy 
and  Morbid  Anatomy. — Adherent  pericardium  is  a  common  result  of  the 
acute  forms  of  the  disease.  It  may  be  partial  or  general.  The  peri- 
cardium is  thick  and  the  adhesions  are  firm.  The  cases  may  be  separated 
into  two  groups  :  (i)  Cases  in  which  the  pericardium  and  the  epicardium 


328  PRACTICE  OF  MEDICINE 

are  united,  and  (2)  those  in  which  the  condition  is  associated  with 
chronic  mediastinitis,  the  outer  layer  of  the  pericardium  being  firmly 
united  with  the  pleura  and  chest-wall.  The  condition  is  described 
under  the  names  pleuropericarditis,  external  pericarditis,  and  mediastino- 
pericarditis.  Simple  adhesion  of  the  pericardium  with  the  epicardium  is 
often  discovered  post  mortem  in  patients  who  never  gave  a  history  of 
pericarditis.  The  more  extensive  adhesions  often  lead  to  extreme  hyper- 
trophy and  dilatation  of  the  heart,  even  in  cases  in  which  only  a  limited 
area  of  the  pericardium  is  involved.  The  condition  is  often  of  tubercular 
origin. 

Symptoms. — The  clinical  manifestations  of  the  disease  are  generally 
a  result  of  the  interference  with  the  free  action  of  the  heart  caused  by 
the  adhesions.  The  condition  is  not  usually  recognized  until  marked 
hypertrophy  has  taken  place.  Cardiac  insufficiency  is  later  developed. 
In  some  cases  the  proliferative  inflammation  extends  from  the  pericar- 
dium to  the  peritoneum  and  produces  similar  thickening  of  that  mem- 
brane, with  perihepatitis  and  perisplenitis.  The  patient  usually  suffers  in 
the  late  stages  of  the  disease  from  urgent  dyspnea,  and  the  cyanosis  is 
often  extreme  after  fatty  degeneration  and  dilatation  of  the  walls  of  the 
heart  have  become  extensive.  The  heart  movements,  as  recognized  by  in- 
spection and  palpation,  are  exceedingly  irregular  and  there  is  sometimes 
a  slight  retraction  or  "  dimpling"  in  the  region  of  the  apex  in  each  sys- 
tole. A  pleural  friction  sound  is  often  heard  in  addition  to  the  pericardial, 
and  often  conceals  the  true  condition  from  the  examiner,  unless  the  pa- 
tient be  instructed  to  hold  his  breath.  The  pulsus  paradoxus  may  be 
present  and  the  veins  of  the  neck  become  distended  during  inspiration. 
Sudden  death  often  occurs  in  this  condition  as  a  result  of  excitement 
or  strong  exertion. 

5.  Tubercular  pericarditis  is  considered  under  the  general  heading  of 
Tuberculosis,  page  186. 

6.  Cancerous  Pericarditis.— This  term  is  commonly  made  to  include 
both  carcinomatous  and  sarcomatous  disease  of  the  pericardium.  They 
are  both  rare  affections  and  probably  always  secondary  in  their  origin. 
In  addition  to  the  neoplastic  tissue  there  is  usually  a  serous  or  hemor- 
rhagic eff'usion  within  the  sac.  The  diagnosis  is  generally  based  upon 
the  severity  of  the  pain,  the  evidences  of  eff"usion,  the  cachexia,  and  the 
discovery  of  a  primary  growth  elsewhere. 

OTHER  AFFECTIONS  OF  THE  PERICARDIUM. 

Hydropericardium  (Dropsy  of  the  Pericardium). — A  noninflammatory 
accumulation  of  serum  within  the  pericardial  sac.  Et/'o/ogy.— The  con- 
dition is  generally  one  of  the  features  and  one  of  the  more  serious  mani- 
festations of  a  general  dropsy.  It  is  most  commonly  a  result  of 
chronic  nephritis,  next  most  frequently  of  valvular  heart  disease,  occa- 
sionally of  pulmonary  emphysema  or  hepatic  cirrhosis.  It  is  a  common 
accompaniment  of  hydrothorax  under  the  same  etiological  conditions. 

The  symptoms  and  physical  signs  are  identical  with  those  of  peri- 
carditis with  effusion,  but  there  is  no  friction,  pain,  or  fever.  The  accu- 
mulation of  fluid  sometimes  becomes  extreme  without  producing  marked 
dyspnea,  but  in  other  cases  this  is  a  prominent  feature. 


DISEASES  OF  THE  HEART  329 

Chylopericardium,  in  which  the  accumulation  has  a  white,  milky  ap- 
pearance, has  been  met  with  in  a  few  instances. 

Hemopericardium. — This  condition,  in  which  the  pericardium  is  more 
or  less  completely  filled  with  blood,  is  generally  a  result  of  penetrating 
wounds,  the  rupture  of  an  aneurism  of  the  aorta,  a  rent  in  the  heart- 
wall  in  advanced  myocarditis,  or  the  rupture  of  the  coronary  artery. 
The  condition  generally  proves  rapidly  fatal,  except  in  some  cases  of 
rupture  of  the  heart  in  which  life  may  be  prolonged  for  a  few  hours  or 
possibly  for  a  few  days.  The  symptoms  are  those  of  more  or  less  rapid 
heart-failure  and  the  signs  of  pericardial  distention. 

Pneumopericardium.— This  is  a  rare  condition  in  which  the  pericar- 
dial sac  becomes  inflated  with  air  or  gas.  It  is  commonly  a  result  of  a 
penetrating  wound  of  the  chest-wall  or  a  perforation  of  the  esophagus, 
stomach,  or  lung  into  the  pericardium,  due  to  wound,  ulcer,  cancer,  or 
tuberculosis.  Gas  may  also  be  formed  in  a  purulent  exudate  by  the 
bacillus  aerogenes  capsulatus.  A  purulent  pericarditis  is  promptly  de- 
veloped in  cases  in  which  it  was  not  previously  present.  The  symptoms 
are  those  of  acute  exudative  pericarditis  with  rapid  heart-failure.  Percus- 
sion reveals  a  changeable  area  of  dullness  with  tympany  over  the  inflated 
area.  On  auscultation  are  heard  churning  and  splashing  sounds,  some- 
times friction,  with  feeble,  distant  heart-sounds.  The  diagnosis  is  gener- 
ally revealed  by  the  history  of  the  case  and  the  physical  signs.  The  prog- 
nosis is  grave.   The  case  often  terminates  fatally  within  the  first  48  hours. 

The  treafmenf  is  surgical,  consisting  of  free  incisions  and  drainage, 
or  enlargement  of  the  opening  in  a  case  of  penetrating  wound.  While 
these  measures  are  justifiable,  they  are  seldom  effectual. 


DISEASES    OF    THE    HEART. 

ENDOCARDITIS. 

Definition. — ^Inflammation  of  the  endocardium.  It  may  affect  any 
portion  of  the  lining  membrane,  but  is  usually  confined  to  the  valves. 
The  process  may  be  acute  or  chronic,  and  the  acute  is  further  subdivided 
into  the  simple  or  benign  form,  and  the  ulcerative  or  malignant- 

SIMPLE  ACUTE  ENDOCARDITIS. 

Etiology. — Acute  endocarditis  is  met  with  at  any  period  of  life,  but 
more  frequently  in  children  and  young  adults.  It  usually  occurs  as  a 
complication  of  an  acute  infectious  disease,  particularly  rheumatism, 
rarely,  if  ever,  as  a  primary  affection.  It  is  probably  of  bacterial  origin 
in  all  cases.  Some  previous  lesion  of  the  endocardium  has  always  been 
regarded  as  necessary  to  the  production  of  endocardial  inflammation, 
a  view  based  largely  upon  the  fact  that  the  endocardium  of  the  right 
heart  was  sometimes  found  to  be  aff"ected  in  the  fetus,  but  the  left  side 
almost  invariably  in  cases  occurring  after  birth.  The  injury  has,  there- 
fore, been  attributed  to  the  force  of  the  blood-current.  At  the  present 
time,  only  such  impairment  of  the  membrane  is  deemed  to  be  essential 
as  will  permit  the  lodgment  and  growth  of  micro-organisms.  It  seems 
probable  that  several   different  organisms  are  capable  of  inducing  the 


330  PRACTICE  OF  MEDICINE 

disease,  and  that  the  endocardium  is  rendered  susceptible  to  their  action 
by  the  toxic  state  of  the  blood  accompanying  the  acute  infections  with 
which  it  is  associated.  Acute  rheumatism  is  the  disease  which  above 
all  others  leads  to  its  development.  There  is  usually  no  relation  between 
the  endocarditis  and  the  severity  of  the  articular  affection,  for  it  often 
develops  upon  nonarticular  cases.  Tonsilitis  in  a  rheumatic  subject 
is  sometimes  complicated  with  endocarditis.  Scarlet  fever,  measles, 
chickenpox,  and  other  infections  of  children  are  sometimes  followed  by 
it.  Pneumonia  and  less  frequently  typhoid  fever,  erysipelas,  diphtheria, 
or  smallpox  may  induce  it,  and  the  valves  not  infrequently  become 
affected  in  such  wasting  diseases  as  diabetes,  gout,  tuberculosis,  .cancer, 
or  chronic  nephritis.  A  chronic  endocarditis  is  liable  to  develop  acute 
attacks,  and  the  sclerotic  valves  resulting  from  chronic  endocarditis 
are  sometimes  the  seat  of  acute  inflammation  (acute  recurrent  endocar- 
ditis). The  liability  to  such  recurrence  is  increased  during  pregnancy 
and  the  puerperal  state. 

Morbid  Anatomy. —  Vegetations,  granular  or  warty 'excrescences,  vary- 
ing in  diameter  from  less  than  i  to  more  than  4  mm.,  are  formed  upon 
the  affected  surface  of  the  endocardium.  They  are  most  frequently 
found  on  the  mitral  valve,  next  most  frequently  on  the  aortic.  They 
are  situated  just  above  the  line  of  closure  of  the  cusps  or  leaflets,  on 
the  auricular  surface  of  the  mitral  valve  and  the  ventricular  surface  of 
the  aortic.  The  vegetations  at  first  consist  of  leucocytes,  blood-plates, 
and  fibrin,  but  a  proliferation  of  the  endothelium  and  of  the  subendo- 
thelial  connective  tissue  is  shortly  induced  and  gradually  replaces  the 
original  vegetations.  It  is  in  this  manner  that  the  vegetations  become 
"organized."  A  layer  of  fibrin  and  leucocytes  is  generally  retained  on 
the  surface.  The  same  process  sometimes  takes  place  on  the  mural 
endocardium  or  over  the  chordae  tendineae.  The  vegetations  are  some- 
times attached  by  a  very  narrow  pedicle.  In  consequence  of  this  loose 
attachment  they  are  sometimes  detached  and  carried  away  as  emboli 
in  the  blood-stream,  but  not  so  frequently  in  the  simple  as  in  the 
ulcerative  form  of  the  disease.  Very  old  vegetations  sometimes  become 
converted  into  firm  connective  tissue  and  are  thus  greatly  reduced  in, 
size;  their  contraction  often  leads  to  deformity  of  the  valves.  They 
sometimes  undergo  subsequent  softening  or  ulceration,  owing  to  the  im- 
pairment of  nutrition  occasioned  by  the  sclerotic  process.  The  bacteria 
which  have  been  found  in  the  vegetations  or  upon  the  surface  are  the 
streptococci,  staphylococci,  pneumococci,  occasionally  gonococci,  and  the 
bacilli  of  typhoid  fever  and  influenza,  the  common  colon  bacillus,  and 
several  other  organisms. 

Symptoms. — Simple  acute  endocarditis  often  develops  without  pro- 
ducing either  clinical  manifestations  or  physical  signs  by  which  it  can 
be  recognized.  Lesions  of  long  standing  are  sometimes  encountered 
after  death  in  persons  who  manifested  no  symptoms  during  life.  In  the 
beginning  there  is  often  an  elevation  of  temperature  amounting  to  102° 
or  103°  F.  (39.0° — 39.5°  C),  but  it  may  be  concealed  by  the  fever 
belonging  to  the  previous  condition.  Under  these  circumstances,  how- 
ever, there  is  generally  a  slight  increase  of  the  fever  without  recognizable 
aggravation  of  the  original  disease,  and,  therefore,  suggesting  the  devel- 
opment  of  a  complication.     There  is  no  pain,  but  the  patient  becomes 


DISEASES  OF  THE  HEART  331 

restless  and  the  heart's  action  becomes  accelerated  and  irregular,  es- 
pecially in  mitral  disease.  The  distinguishing  feature  of  the  disease  is 
the  presence  of  a  murmur.  This  is  at  first  little  more  than  a  roughening 
of  the  first  sound.  The  character  of  the  sound  after  it  has  developed 
into  a  distinct  murmur,  and  the  area  of  its  greatest  intensity,  depend 
upon  the  valve  affected  and  the  manner  in  which  it  is  affected.  No 
greater  mistake  is  made,  and  probably  none  more  frequently,  than  in 
the  assumption  that  every  heart  murmur  indicates  a  present  or  previous 
endocarditis. 

Diagnosis. — The  diagnosis  depends  upon  the  sudden  development  of 
a  heart  murmur  with  irregular  action  in  the  presence  of  a  recognized 
causative  condition,  as  during  the  course  of  acute  rheumatism.  But 
when  the  valves  are  only  slightly  or  not  at  all  affected,  there  may  be 
no  murmur,  and  in  any  case  the  sound  may  be  heard  only  at  intervals. 
Anemic  and  other  functional  murmurs  must  be  differentiated. 

Prognosis.  —  The  disease  is  not  necessarily  fatal,  but  it  generally 
leaves  the  heart  in  an  impaired  condition.  Each  recurrence  increases 
the  liability  to  sclerosis,  the  extent  of  the  sclerosis,  the  consequent  de- 
formity of  the  valves  and  their  insufificiency.  This  in  turn  induces  greater 
hypertrophy  and  hastens  the  approach  of  dilatation  and  incompetency. 
(See  p.  335-)  Many  patients  live  to  advanced  age,  however,  after 
having  passed  through  several  attacks,  and  permanent  recovery  un- 
doubtedly takes  place  in  some  cases. 

Treatment. — The  patient  should  be  given  completer  est.  Rest  is  im- 
portant as  a  prophylactic  measure  during  any  illness  which  is  liable 
to  induce  endocarditis;  it  is  in  fact  the  only  means  at  our  command 
for  warding  off  the  disease.  The  rapid,  irregular  action  of  the  heart  may 
often  be  quieted  to  some  extent  by  the  application  of  an  ice-bag.  Salt 
should  not  be  added  to  the  ice,  for  in  careless  hands  the  skin  may  be 
quickly  frozen.  When  the  disease  is  associated  with  rheumatism,  the 
salicylates  should  be  continued  in  full  doses.  Some  writers  advocate 
their  use  also  in  cases  arising  from  other  causes.  The  sulphocarbolates, 
ammonium  carbonate,  and  alkalis  in  general  are  regarded  as  beneficial. 
The  diet  should  be  mostly  liquid,  but  abundant,  and  stimulation  is 
generally  required.  Strychnin  in  small  doses  should  be  given  during  con- 
valescence. The  patient  should  not  be  permitted  to  exert  himself  for 
several  weeks  after  apparently  complete  recovery. 

MALIGNANT  OR   ULCERATIVE   ENDOCARDITIS. 
Infectious,  Septic,  or  Diphtheritic  Endocarditis. 

Etiology. — ((S-)  It  is  now  pretty  generally  admitted  that  malignant 
endocarditis  may  arise  as  a  primary  affection;  ((^)  in  a  majority  of  cases, 
however,  it  develops  secondarily,  in  a  heart  that  has  been  previously 
affected  with  endocarditis,  or  it  may  follow  immediately  upon  an  attack 
of  the  acute  form.  In  either  instance  it  is  due  to  the  action  of  one  of 
the  pyogenic  micro-organisms,  especially  the  micrococcus  pyogenes  or 
the  micrococcus  lanceolatus.  It  is  often  closely  related  to  a  process  of 
suppuration,  as  otitis  media,  gonorrhea,  puerperal  fever,  but  it  occurs 
more  frequently  in  connection  with  pneumonia,  sometimes  with  erysipelas 


2^2,2  PRACTICE  OF  MEDICINE 

or  dysentery.  In  many  cases  the  direct  source  of  infection  cannot  be 
determined.  It  is  not  common  in  connection  with  rheumatism,  nor  is 
it  encountered  in  cases  of  chorea.  It  is  rare  in  measles,  diphtheria,  scarlet 
fever,  smallpox,  typhoid  fever,  and  tuberculosis. 

Morbid  Anatomy. — In  the  beginning  of  the  disease,  vegetations  are 
found  upon  the  affected  endocardium,  as  in  simple  endocarditis,  but 
necrosis  soon  develops.  The  resultant  loss  of  tissue  causes  a  thinning 
and  weakening  of  the  valve  and  often  leads  to  rents  and  perforations. 
Suppuration  sometimes  occurs  within  the  vegetations,  producing  minute 
abscesses  and  increasing  the  liability  to  perforation  or  to  the  formation 
of  the  so-called  aneurisms  of  the  valves.  Excessively  large  and  long 
verrucose  vegetations  are  occasionally  found  upon  the  valves  without 
loss  of  substance.  The  necrotic  process  often  invades  also  the  mural 
endocardium,  causing  more  or  less  complete  perforation  of  the  ventricu- 
lar septum,  errosion  and  sometimes  rupture  of  the  chordae  tendineae, 
rarely  of  the  heart-wall  itself.  Fragments  of  the  vegetations  are  some- 
times torn  away  and  carried  with  the  blood  to  produce  one  or  many 
embolisms  in  remote  parts,  especially  in  the  lungs,  liver,  intestines, 
spleen,  kidneys,  brain,  or  elsewhere.  The  lesions  are  commonly  found 
in  the  mitral  valves,  next  in  the  aortic,  and  almost  as  often  in  both, 
but  rarely  in  those  of  the  right  heart.  Among  Osier's  209  cases,  the 
disease  was  confined  to  the  mitral  valve  in  77,  to  the  aorta  in  53, 
affecting  both  in  41;  the  tricuspid  was  affected  in  19,  the  pulmonary 
in  15,  and  the  heart  walls  in  33.  Hemorrhagic  pericarditis,  petechial, 
erythematous  eruptions,  and  general  purpura  are  not  uncommon  com- 
plications. Purulent  inflammation  of  the  joints  and  general  pyemia  are 
possible  results.  The  ulcerative  process  sometimes  extends  outward 
from  the  affected  endocardium,  along  the  intima  of  the  valves,  produc- 
ing endarteritis,  especially  in  the  aorta. 

The  bacteria  found  in  the  lesions  are  the  same  as  those  in  simple 
endocarditis,  but  the  micrococcus  lanceolatus  and  the  streptococcus 
pyogenes  are  more  constantly  encountered. 

Symptoms.— The  clinical  course  of  mahgnant  endocarditis  is  exceed- 
ingly variable.  Two  definite  types  of  manifestations  are  encountered, 
the  one  corresponding  closely  to  those  of  sepsis,  the  other  assuming  a 
typhoid  course,  but  many  cases  are  more  markedly  intermittent  in  char- 
acter. In  some  cases  the  manifestations  of  the  local  disease  are  promi- 
nent, while  in  others  they  are  so  slight  as  to  be  readily  overlooked. 
The  most  striking  features  in  all  cases,  however,  are  directly  referable 
to  septic  infection. 

The  onset  is  usually  sudden,  with  a  distinct  rigor,  or,  if  the  disease 
develops  in  the  course  of  a  febrile  affection,  there  is  a  sharp  increase 
of  fever,  often  to  104°  or  105°  F.  (40^—40.5°  C).  The  pulse  becomes 
feeble,  rapid,  and  irregular,  often  dicrotic.  The  subsequent  temperature 
curve  varies  with  the  type  of  the  symptoms  in  each  case. 

In  the  sej>^u  type,  repeated  chills  occur,  followed  with  profuse  sweats, 
great  prostration,  and  other  symptoms  of  sepsis.  The  chills  sometimes 
occur  with  a  regularity  that  suggests  quotidian  or  tertian  intermittent 
fever.  Heart  symptoms  of  greater  or  less  severity  may  be  present,  but 
very  often  they  are  so  mild  as  to  be  entirely  obscured  by  the  general 
condition. 


DISEASES  OF  THE  HEART  ^^^ 

The  typhoid  type  is  more  common.  It  is  characterized  by  a  more  uni- 
form temperature  curve  and  greater  nervous  disturbance,  headache, 
restless  sleep,  delirium  finally  passing  into  coma.  More  active  cerebral 
symptoms  sometimes  appear,  the  case  being  readily  mistaken  for  one 
of  basilar  or  ccrebro-spinal  meningitis.  Profuse  sweats  generally  occur, 
and  petechitil,  erythematous,  and  other  cutaneous  eruptions  may  appear. 
The  tongue  is  heavily  coated,  sordes  collect  on  the  teeth,  and  abdominal 
distention,  with  diarrhea  or  constipation  and  vomiting— these  are  fea- 
tures of  many  cases.  In  this  form,  as  in  the  septic,  the  endocarditis  may 
be  entirely  overlooked;  it  may,  in  fact,  be  unrecognizable  upon  the 
most  careful  examination. 

Embolisms. — The  course  of  the  disease  may  be  suddenly  changed  by 
the  development  of  embolism  in  one  or  more  parts,  with  manifestations 
peculiar  to  the  part  affected.  They  are  generally  announced  by  a  sud- 
den localized  pain  corresponding  to  the  location.  A  chill  often  announces- 
the  dissemination  of  the  emboli.  Following  their  lodgment  there  are 
evidences  of  inflammation,  and,  later,  those  pointing  to  the  formation  of 
an  abscess.  There  is  then,  as  a  rule,  tenderness  on  pressure,  especially 
over  the  liver,  spleen,  or  kidneys.  Infarction  or  abscess  of  the  lung  or 
empyema  may  follow  a  pulmonary  embolism;  albuminuria,  hematuria, 
and,  later,  pyuria,  that  of  the  kidney.  Jaundice  commonly  accompanies 
other  evidences  of  embolism  of  the  liver. 

Heart  Syviptoms.—T\\.^  valvular  lesions  are  all  the  more  serious  in  their 
consequences  because  they  are  so  suddenly  developed.  Congestion  of 
the  lungs  is  a  constant  result,  a  condition  that  is  manifested  in  extreme 
dyspnea  and  marked  cyanosis ;  edema  of  the  lung  may  also  be  induced. 
These  disturbances  are,  as  a  rule,  more  severe  when  the  disease  attacks 
a  previously  healthy  endocardium  than  one  that  has  been  the  seat  of 
old  valvular  lesions,  for  in  the  latter  condition  the  heart,  already  hyper- 
trophied,  is  better  able  to  overcome  the  circulatory  derangement  that 
is  set  up. 

Diagnosis. — When  the  heart  symptoms  are  prominent,  the  diagnosis  is 
not  difficult;  in  their  absence,  it  may  be  extremely  so.  It  is  generally 
to  be  based  upon  the  history  of  the  previous  affection,  the  sudden  onset, 
with  chill,  high  fever,  sweating,  and  the  characteristic  physical  signs,  when 
present.  The  development  of  embolism  throws  additional  light  upon 
the  case.  The  differentiation  from  a  simple  endocarditis  is  not  difficult. 
In  a  majority  of  cases  the  symptoms  resemble  either  general  septicemia 
or  typhoid  fever.  As  the  clinical  manifestations  are  in  reality  septic 
there  can  be  no  differentiation  between  the  condition  and  sepsis,  in  the 
absence  of  a  history  of  previous  valvular  involvement  or  present  cardiac 
symptoms. 

The  differential  diagnosis  lies  between  typhoid  fever,  malaria,  and 
acute  miliary  tuberculosis. 

Typhoid  fever  is  to  be  excluded  by  the  fact  that  the  disease  follows  a 
pneumonia  or  other  infectious  disease,  as  well  as  by  the  sudden  onset 
without  prodromes,  the  rapid  rise  of  temperature,  early  prostration, 
the  irregular  or  intermittent  course  of  the  fever,  the  presence  of  cardiac 
symptoms,  marked  leucocytosis,  and  probably  by  the  development  of 
embolisms. 

Intermittetit  fever  and  other   forms   of   malaria   are  excluded    by    the 


334  PRACTICE  OF  MEDICINE 

absence  of  the  Plasmodium  from  the  blood,  and  usually,  upon  close 
observation,  by  the  irregular  periodicity  of  the  chills  and  sweats. 

Acute  tuberculosis  is  attended  with  pulmonary  symptoms,  usually 
with  enlargement  of  lymph-glands,  and  the  bacillus  tuberculosis  may  be 
found  in  the  sputum.  The  difficulty  of  arriving  at  a  differential  diagnosis 
is  greater  when  either  of  these  affections  occurs  in  the  subject  of  a  val- 
vular lesion. 

Prognosis. — The  disease,  when  severe,  always  terminates  fatally.  The 
correctness  of  the  diagnosis  may  generally  be  questioned  when  recovery 
occurs.    A  few  undoubted  recoveries  have,  nevertheless,  been  observed. 

Treatment. — The  treatment  is  that  of  other  pyemic  affections,  with 
local  applications  to  the  precordial  region  when  indicated.  Perfect  rest 
is  essential.  The  strength  of  the  patient  should  be  maintained  by  a 
nutritious,  mostly  liquid  diet  and  the  regular  and  free  administration 
of  alcohol  and  strychnin.  The  salicylates  and  other  alkalis  are  distinctly 
beneficial  in  some  cases,  and  quinin  in  full  doses  in  others.  It  is  improb- 
able, however,  that  any  form  of  medication  exerts  much  influence  upon 
the  morbid  process.  An  ice-bag  to  the  region  of  the  heart  may  quiet 
its  action  and  possibly  to  some  extent  reduce  the  inflammation  in  cases 
characterized  by  pronounced  local  disturbance. 

CHRONIC   ENDOCARDITIS. 

Chronic  Interstitial  or  Sclerotic  Endocarditis,  Chronic  Valvular  Disease 

OF  the  Heart. 

Etiology. — There  are  two  groups  of  cases  :  (a)  A  majority  of  cases 
follow  an  acute  endocarditis  and  are  marked  by  rapid  progress ;  and  Qb^ 
cases  which  run  a  chronic  course  from  the  beginning.  Going  back  a 
step  further,  the  starting-point  of  the  condition  in  fully  half  the  cases 
is  an  attack  of  acute  articular  rheumatism,  and,  in  a  majority  of  the 
remaining  cases,  it  is  one  of  the  other  infectious  diseases  that  have 
been  referred  to  under  the  etiology  of  acute  endocarditis.  Like  acute 
endocarditis,  too,  it  is  more  frequent  in  young  persons  than  in  those 
beyond  middle  life.  The  disease  more  commonly  attacks  the  mitral 
valve.  It  is  probable  also  that  many  cases  which  appear  to  begin 
insidiously  and  to  pursue  a  chronic  course  from  the  beginning,  originate 
in  some  mild  affection  during  which  no  involvement  of  the  heart  was 
recognized.  In  other  instances,  the  slowly  progressing  sclerosis  is  induced 
by  alcoholism,  syphilis,  chronic  nephritis,  gout,  toxic  substances  in  the 
blood,  and  sometimes,  no  doubt,  by  habitually  excessive  exercise.  In  a 
large  group  of  cases  the  condition  is  part  of  a  general  arteriosclerosis. 

Morbid  Anatomy. — In  this,  as  in  the  acute  form  of  the  disease,  the 
primary  lesion  is  in  most  cases  the  warty  vegetation,  but  the  sclerotic 
process  reduces  these  excrescences  to  minute,  hard  nodules  and  they 
are  often  no  longer  discernible.  The  edges  of  the  valves  now  appear 
opaque,  yellowish  gray,  uniformly  thickened,  firm,  and  inelastic.  In 
the  aortic  valve  the  sclerosis  begins  around  the  corpora  Arantii;  in  the 
auriculoventricular  valves,  it  begins  just  within  the  margin  of  the  leaf- 
lets. The  appearances  are  often  very  similar  to  those  of  arteriosclerosis 
in  the  aorta.    As  a  later  change,  the  valves  become  misshapen,  corru- 


VALVULAR  DISEASES  OF  THE  HEART  335 

gated,  curled,  and  variously  distorted.  They  may  become  shrunken  into 
mere  stumps,  and  the  leaflets  may  become  adherent  over  a  variable 
portion  of  their  lines  of  contact,  forming  an  annular  diaphragm.  So 
long  as  this  agglutination  does  not  occur,  the  most  extensive  thicken- 
ing and  deformity  of  the  segments  may  be  found,  the  valves  being  ren- 
dered functionally  useless,  permitting  extreme  regurgitation,  without 
occasioning  appreciable  stenosis.  When,  however,  the  edges  have  become 
adherent,  the  subsequent  contraction  necessarily  induces  some  degree  of 
stenosis.  The  orifice  sometimes  has  a  funnel-like  appearance.  In  another 
class  of  cases  the  leaflets  become  firmly  attached  to  the  mural  endo- 
cardium immediately  back  of  them,  or,  in  cases  of  the  aortic  valve,  to 
the  intima  of  the  vessel,  thus  preventing  them  from  coming  into  apposi- 
tion to  close  the  orifice.  The  chordae  tendineae  generally  become  in- 
•  volved  in  the  sclerosis,  beginning  at  their  attachments  to  the  valves 
and  extending  to  a  variable  part  of  their  length,  sometimes  beyond  them 
into  the  papillary  muscles.  The  edges  of  the  valve  leaflets  are  thus 
drawn  together  and  the  orifice  correspondingly  narrowed.  Calcification 
of  the  degenerated,  sclerotic  tissue  of  the  valves  is  a  common  result  of 
the  process,  sometimes  so  extreme  as  to  convert  the  entire  valve  into  a 
calcareous  plate.  Ulceration  resembling  that  of  atheromatous  disease 
may  occur  or  a  true  ulcerative  endocarditis  may  be  set  up  at  the  edges 
of  these  plates  or  beneath  them.  The  warty  vegetations  of  acute  endo- 
carditis may  also  be  found,  and  over  the  surface  there  is  not  infrequently 
deposited  a  layer  of  fibrin  from  the  blood.  The  changes  that  occur  in 
the  valves  of  the  right  heart  are  identical  in  character  with  those  just 
described,  but  they  are  much  less  frequent.  The  walls  of  the  heart, 
especially  those  of  the  ventricles,  are  enormously  thickened  during  the 
existence  of  compensatory  hypertrophy,  but,  after  dilatation  has  super- 
vened, they  are  often  reduced  to  extreme  thinness.  Both  conditions 
are  frequently  found  coincidently  in  diff"erent  chambers. 

VALVULAR  HEART  DISEASE. 

Under  this  heading  may  be  conveniently  studied  the  results  of  the 
different  forms  of  endocarditis  of  the  valves. 

The  eff'ect  of  endocarditis  upon  the  valves  is  to  produce  either  (a;) 
incompetency  (insufficiency,  with  regurgitation  of  blood),  or  (^b~)  steno- 
sis (partial  closure  of  the  orifice).  Either  of  these  conditions  may  exist 
separately  in  either  of  the  valves,  or  they  may  be  combined,  affecting 
the  same  or  different  valves  at  the  same  time. 

Incompetency,  or  insufiiciency,  is  a  condition  in  which  the  complete 
closure  of  the  valve  is  prevented  by  erosion,  perforation,  deformity,  or 
adventitious  bands  and  adhesions.  It  permits  the  blood  to  flow  through 
the  orifice  in  an  abnormal,  reversed  direction.  Stenosis,  or  narrowing, 
of  the  valve  orifice,  on  the  other  hand,  prevents  the  normal  flow  of 
blood  through  it.  As  a  result  of  either  condition  a  chamber  of  the 
heart  is  engorged  with  blood;  yielding  to  the  increased  blood-pressure 
within,  it  becomes  acutely  distended.  The  heart  possesses  a  certain  de- 
gree of  reserve  force  which  enables  it  for  a  time  to  meet  the  emergency, 
however  suddenly  it  may  occur,  as  it  ordinarily  does  the  distention 
caused  by  sudden  active  exercise.    In  most  cases  a  valve  lesion  develops 


336  PRACTICE  OF  MEDICINE 

gradually,  the  distention  of  the  cavity  is  correspondingly  slow,  and  the 
reserve  force  is  sufficient  to  carry  on  the  circulation  without  serious 
interruption  until  another  change  has  had  time  to  occur,  namely,  a 
hypertrophy  of  its  walls.  This  is  known  as  a  compensatory  hyper- 
trophy. The  increased  muscular  power  of  the  heart,  in  other  words, 
compensates  for  the  valvular  leakage.  The  walls  become  thickened  and 
the  blood  is  carried  in  increased  quantity  and  with  increased  force  from 
the  enlarged  cavity  through  the  defective  orifice.  The  loss  to  the  general 
circulation  that  would  otherwise  result  from  either  regurgitation  or 
stenosis  is  thus  prevented.  Compensatory  hypertrophy  may  enable  the 
heart  to  perform  its  function  with  regularity  for  a  long  time,  but  it 
cannot  restore  the  integrity  of  the  organ.  With  the  increase  of  muscular 
force,  or  working  power,  there  is  a  corresponding  diminution  of  the 
reserve  force,  and  the  heart  is  no  longer  able  fully  to  meet  emergencies. 
Unusual  exertion  is  met  with  increased  action,  but  it  is  the  increased 
action  of  an  abnormally  large  and  strong  heart ;  as  a  result,  the  blood- 
vessels become  engorged,  the  rhythm  is  disturbed,  and  more  remote 
disturbances  follow,  depending  in  character  upon  the  valve  affected  and 
the  nature  of  the  lesion.  This  is  known  as  a  disturbance  of  compensa- 
tion. The  compensation  fails  at  first  only  when  the  heart  is  called  upon 
to  perform  extra  work,  but  the  failure  becomes  permanent  if  the  heart 
is  constantly  subjected  to  undue  strain.  The  failure  is  gradual,  however, 
and  for  a  time  after  the  heart  is  unable  to  perform  extra  work  it  is 
still  capable  of  maintaining  the  circulation  with  the  body  at  rest.  A 
final  failure  usually  occurs,  and  the  organ  can  no  longer  perform  its 
function  under  the  most  favorable  conditions. 

With  the  decline  of  the  muscular  power  in  the  walls  of  the  heart,  the 
chambers  become  more  enlarged,  and  a  condition  of  extreme  and  per- 
manent dilatation  is  produced.  A  very  remarkable  form  of  compensa- 
tion has  been  described  in  which  the  shrinkage  of  one  valve  segment 
through  sclerosis  is  met  with  a  compensatory  lengthening  of  the  other 
segments,  but  it  is  at  least  an  extremely  exceptional  possibility. 

The  dilatation  and  loss  of  compensation  are  often  greatly  hastened 
by  degenerative  changes  in  the  heart  muscle.  This  is  particularly  the 
case  when  the  circulation  through  the  coronary  arteries  is  impeded  and 
the  nutrition  of  the  organ  diminished.  The  same  result  is  produced 
to  some  extent  also  by  the  anemic  condition  of  the  system,  and  this 
in  turn  may  be  added  to  by  poor  food,  alcoholism,  mental  emotions, 
or  any  illness,  especially  an  acute  febrile  disease.  The  special  changes 
in  the  different  chambers  of  the  heart  are  considered  in  connection  with 
the  affections  of  each  valve. 

Remote  Effects  of  Valvular  Lesions. — The  more  direct  effects  of  val- 
vular disease  are  seen  in  the  lungs,  but  changes  occur  also  in  the  liver, 
spleen,  kidneys,  and,  in  cases  of  long  standing,  in  almost  every  organ 
of  the  body.  The  pulmonary  vessels  are  greatly  distended,  and  as  com- 
pensation is  lost  they  become  permanently  dilated.  Their  branches 
often  become  distinctly  varicosed.  The  circulation  is  sluggish  and  the 
lungs  appear  deeply  congested.  Proliferation  of  the  fibrous  tissue  with 
pigmentation  leads  to  brown  induration.  Areas  of  collapse  are  some- 
times produced,  and  infarctions  often  form  within  the  dilated  vessels. 
The  condition  of  the  liver  is  that  known  as  chronic  passive  hyperemia. 


VALVULAR  DISEASES  OF  THE  HEART  337 

The  organ  is  enlarged,  the  blood-vessels  dilated,  the  connective  tissue 
proliferated,  and  pigment  is  at  the  same  time  deposited  about  the  cen- 
tral vein  of  the  lobule.  The  spleen,  kidneys,  stomach,  and  intestines  are 
also  congested. 

MITRAL   IXCOMPETEN'CV. 

Etiology. — Mitral  insufficiency  is  the  most  frequent  form  of  valvular 
defect.  It  may  occur  at  any  time  of  life,  but  commonly  affects  younger 
persons  than  are  the  subjects  of  aortic  lesions.  It  is  slightly  more  fre- 
quent in  women.  In  a  majority  of  cases  it  is  due  to  endocarditis  fol- 
lowing rheumatism.  It  may  depend  upon:  (d;)  Changes  in  the  segments 
of  the  valves,  shortening,  deformity,  or  retraction,  with  which  there 
are  generall}^  associated  a  thickening  and  shortening  of  the  chordse.  ten- 
dineae.  Qli)  The  segments  may  be  normal,  yet  prevented  from  accurate 
coaptation  and  closure  of  the  orifice  by  extreme  dilatation  of  the  ven- 
tricle or  improper  action  of  the  papillary  muscles.  This  is  known  as 
muscular  incompetency.  A  variable  degree  of  stenosis  is  usually  as- 
sociated with  the  incompetency,  but  less  frequently  in  cases  affecting 
children. 

From  this  purely  mitral  condition  there  is  to  be  distinguished  a 
relative  insufficiency  that  ensues  upon  excessive  dilatation  of  the  left 
ventricle  as  a  result  of  profound  anemia,  myocarditis,  or  loss  of  tone 
in  the  heart  muscles  due  to  prolonged  febrile  or  wasting  disease,  all  of 
which  conditions  render  the  valve  segments  incapable  of  closing  the 
relaxed  or  dilated  orifice.  A  relative  insufficiency  sometimes  results 
from  a  sudden  destruction  of  an  aortic  segment.  The  left  ventricle  is 
dilated,  the  mitral  valve  rendered  incompetent,  and  the  lungs  are  en- 
gorged, sometimes  to  the  extent  of  producing  slight  hemoptysis.  The 
hypertrophy  of  the  left  ventricle,  associated  with  chronic  interstitial 
nephritis,  occasionally  yields  to  dilatation,  and  pulmonary  and  systemic 
engorgement  results,  which  resembles  that  of  a  primary  mitral  lesion. 
In  the  same  way  the  hypertrophy  due  to  overwork,  alcoholism,  or  peri- 
carditis in  children  may  lead  to  conditions  almost  identical  with  those 
of  mitral  incompetency. 

Pathology. — (c?)  With  each  systole  of  the  left  ventricle,  a  part  of  the 
blood  is  thrown  back  through  the  imperfectly  closed  mitral  orifice  into 
the  auricle.  This  blood,  together  with  that  entering  from  the  pulmonary 
veins,  produces  a  dilatation  of  the  auricle.  Hypertrophy  ensues,  but  the 
walls  of  the  auricles  are  incapable  of  extensive  hypertrophy,  and  the  con- 
dition may  be  regarded  as  one  of  dilatation  alone.  (/^)  An  increased 
quantity  of  blood  is  thrown  into  the  left  ventricle  with  each  auricular 
systole,  causing  dilatation  of  this  chamber  also.  To  meet  this,  the  wall 
of  the  ventricle  undergoes  hypertrophy,  and  the  normal  pressure  within 
the  aorta  is  maintained,  (r)  The  regurgitation  of  blood  into  the  left 
auricle  during  each  diastole  of  the  ventricle,  in  addition  to  producing 
the  changes  described,  prevents  the  normal  flow  of  blood  from  the  pul- 
monary veins,  and  these  vessels  are  dilated.  The  pulmonary  circulation 
is  obstructed  and  (^/)  the  pressure  in  the  right  ventricle  is  increased. 
As  a  result,  this  chamber  becomes  dilated  and  hypertrophied.  (^) 
Dilatation  and  hypertrophy  of  the  auricle  are  finally  produced,  usually 


338  PRACTICE  OF  MEDICINE 

after   tricuspid  regurgitation   has   resulted   from   the  extreme  dilatation 
of  the  ventricle. 

The  hypertrophy  of  the  ventricles  enables  the  heart  to  maintain  the 
normal  blood-pressure  until  subsequent  degenerative  changes  occur.  The 
hypertrophy  then  giv^es  place  to  greater  dilatation,  and  failure  of  com- 
pensation ensues. 

Relative  incompetency,  due  to  muscular  relaxation  and  the  other 
influences  that  have  been  referred  to,  is  seldom  followed  by  full  com- 
pensation. 

Sympioms. — The  severit}'  of  the  symptoms  varies  inversely  with  the 
degree  of  compensation.  When  the  disease  develops  suddenly  with  the 
rupture  of  a  valve,  symptoms  of  extreme  incompetency  are  manifested. 
But  when  the  incompetency  develops  slowly,  the  reserve  force  of  the 
heart  and  the  prompt  hypertrophy  may  maintain  the  circulation  to 
such  an  extent  that  no  subjective  manifestations  are  produced.  In  most 
cases,  however,  the  patient  experiences  shortness  of  breath,  palpitation 
of  the  heart,  and  slight  cyanosis  after  exertion.  In  some  cases  the  cyano- 
sis is  more  constant.  The  face  is  somewhat  congested,  the  lips,  ears, 
and  finger-nails  have  a  bluish  tinge.  In  cases  of  long  standing,  es- 
pecially in  children,  the  fingers  become  clubbed.  The  compensation 
may  become  so  perfect,  however,  either  spontaneously  or  through  treat- 
ment, that,  although  some  of  these  evidences  of  the  disease  remain,  the 
patient  is  able  to  pursue  his  usual  occupation  for  many  years.  Such 
persons  are  more  liable,  however,  to  attacks  of  bronchitis,  and  slight 
hemoptysis  is  likely  to  occur  as  a  result  of  the  pulmonary  engorge- 
ment. 

With  the  failure  of  compensation,  the  symptoms  become  more  intense 
and  more  constant,  as  a  result  of  the  rapid  increase  of  venous  engorge- 
ment. Dyspnea  becomes  constant  and  it  is  often  accompanied  with 
cough  and  watery,  sometimes  bloody,  expectoration  containing  pigmented 
alveolar  epithelium.  Cyanosis  is  not  always  a  constant  feature,  but  it 
is  sometimes  intense,  particularly  after  exertion  or  coughing.  The  sleep 
is  often  restless  and  broken  by  sensations  of  suffocation.  The  peripheral 
veins  become  distended,  and  the  skin  has  sometimes  an  icteric  hue. 
Dropsy  ensues,  beginning  in  the  feet  and  ankles,  and  gradually  invad- 
ing the  body,  particularly  the  serous  cavities.  The  liver  is  enlarged. 
The  urine  becomes  scant  and  albuminous,  usually  containing  epithelial, 
granular,  or  blood  casts.  Gastric  and  intestinal  digestion  is  impaired. 
After  repeated  attacks  of  this  character,  and  repeated  relief  by  treatment, 
a  stage  is  finally  reached  which  can  no  longer  be  mastered,  and  death 
ensues  from  pulmonary  edema  or  the  extreme  cardiac  dilatation,  rarely 
from  sudden  heart-failure. 

Physical  Signs. — Inspection. — The  impulse  of  the  heart  is  forcible  and 
heaving  during  the  stage  of  full  compensation,  but  wavy  and  feeble  after 
compensation  has  failed.  The  apex  beat  cannot  always  be  seen.  The 
precordial  region  is  sometimes  prominent  in  children. 

Palpation. — A  strong  impulse  can  be  felt  bejieath  the  sternum,  over 
a  variable  distance  to  the  right  of  it,  and  to  the  left  as  far  as  the  axil- 
lary line  in  extreme  cases.  The  position  of  the  apex  beat  is  not  constant, 
but  varies  with  the  relative  enlargement  of  the  ventricles  and  the  total 
enlargement  of  the  heart.     It  is  usualh'  found  to  the  left  of  the  nipple. 


VALVULAR  DISEASES  OF  THE  HEART  339 

sometimes  in  the  axillary  line.  It  may  be  as  low  as  the  sixth  intercostal 
space,  but  is  higher  in  extreme  dilatation  of  the  right  ventricle.  A 
thrill  at  the  apex  is  pathognomonic  of  mitral  incompetency,  but  it  is 
seldom  to  be  felt. 

Percussion. — The  area  of  percussion  dullness  is  greatly  increased,  par- 
ticularly in  the  lateral  direction.  In  cases  of  long  standing,  with  great 
dilatation  of  the  ventricles,  it  may  extend  from  one  or  two  inches  (2.5 — 
5.0  cm.)  to  the  right  of  the  sternum  to  three  or  four  inches  (7.5 — 10. o 
cm.)  left  of  the  nipple.  The  upper  margin  of  the  dullness  is  little,  if 
any,  higher  than  normal. 

Auscultation. — The  characteristic  sign  of  mitral  insufficiency  is  a  sys- 
tolic murmur  heard  with  greatest  intensity  at  the  apex,  or  in  many 
cases  a  little  beyond  it.  The  first  sound  is  often  entirely  replaced  by  it. 
The  murmur  is  transmitted  with  great  distinctness  to  the  axilla  and 
generally  to  the  angle  of  the  scapula  as  well  as  a  variable  distance  up- 
ward and  downward  along  the  spine.  In  many  cases  it  is  audible  over  all 
parts  of  the  chest.  It  is  usually  of  a  blowing  or  puffing  quality,  some- 
times ending  in  a  musical  tone,  but  it  may  be  so  harsh  and  loud  as  to 
be  heard  a  distance  of  a  few  inches  from  the  chest.  When,  however,  the 
dilatation  of  the  right  ventricle  is  excessive,  and  the  apex  is  pushed 
back  from  the  chest-wall,  the  murmur  may  be  indistinct  or  almost  in- 
audible. In  many  cases,  too,  it  becomes  audible  only  after  slight  exer- 
tion or  when  the  patient  leans  forward  or  lies  upon  his  back.  Sometimes 
it  is  heard  best  along  the  left  margin  of  the  sternum. 

A  rough  presystolic  murmur  sometimes  accompanies  the  systolic, 
probably  as  a  result  of  an  associated  mitral  stenosis.  A  soft  tricuspid 
murmur  of  regurgitation  is  occasionally  heard  with  it  over  the  lower 
sternal  region  in  cases  of  extreme  dilatation  of  the  right  ventricle.  The 
second  sound  at  the  apex  is  generally  distinctly  heard,  and  the  pulmo- 
nary second  sound  is  accentuated.  It  is  heard  in  the  second  interspace 
at  the  left  of  the  sternum.  The  loudness  and  other  qualities  of  the  mur- 
mur give  but  little  indication  of  the  character  or  gravity  of  the  valvular 
defect.  The  pulse  is  generally  irregular,  and  often  extremely  so  in  the 
beginning.  After  compensation  becomes  completely  established,  or  under 
proper  treatment,  it  may  become  full  and  fairly  regular,  but  a  moderate 
irregularity  generally  persists. 

Diagnosis. — The  most  typical  signs  of  mitral  regurgitation  are  :  ((^7) 
Increased  dullness  in  a  lateral  direction,  indicating  great  transverse 
enlargement  of  the  ventricles;  (^)  a  systolic  murmur  heard  with  greatest 
intensity  at  the  apex,  but  transmitted  to  the  axilla  and  back;  and  (r) 
accentuation  of  the  pulmonary  second  sound.  The  condition  is  most 
readily  confounded  with  the  so-called  accidental,  or  hemic,  murmurs  and 
less  definitely  understood  conditions.  These  sounds,  no  doubt,  originate 
within  the  ventricle,  and  they  may  be  transmitted  to  the  axilla.  The\- 
are  usually  soft  and  blowing  in  character,  and  they  are  not  associated 
with  dilatation  or  accentuation  of  the  pulmonary  second  sound.  The 
history  of  the  previous  condition  is  also  different,  being  in  one  case  an 
infection,  in  the  other  an  abnormal  state  of  the  blood. 

It  is  not  always  possible  to  determine  whether  the  regurgitation  is 
due  to  an  actual  lesion  of  the  valve  leaflets  or  to  a  dilatation  of  the 
ventricle  and  consequent  enlargement  of  the  orifice  due  to  overwork. 


340  PRACTICE  OF  MEDICINE 

arteriosclerosis,  or  other  cause.  Some  writers  have  asserted  that  an 
organic  mitral  lesion  sufficient  to  produce  incompetency  cannot  be  diag- 
nosticated with  certainty  in  the  absence  of  a  presystolic  murmur  indic- 
ative of  stenosis. 

MITRAL  STENOSIS. 

Etiology. — Narrowing  or  obstruction  of  the  mitral  orifice  generally 
occurs  in  young  subjects  and  it  is  considerably  more  frequent  in  females. 
Congenital  cases  have  been  noted.  It  is  generally  due  to  endocarditis 
following  rheumatism  or  one  of  the  other  diseases  which  lead  to  it. 
In  some  cases  no  cause  can  be  positively  determined.  This  possibility 
of  its  originating  in  a  mild  attack  of  one  of  the  other  acute  infections 
should  be  borne  in  mind  in  obscure  cases. 

Morbid  Anatomy. — The  obstruction  may  be  found  to  depend  upon  a 
thickening  of  the  valve  curtains,  upon  an  agglutination  of  their  edges,  or 
upon  induration  of  the  valve-ring.  The  condition  may  be  so  complete  as 
to  give  the  valve  a  funnel  shape  or  to  leave  only  a  buttonhole  slit, 
too  small  to  admit  the  tip  of  the  finger.  The  cusps  may  be  greatly 
deformed,  curled  or  twisted,  or  they  may  be  converted,  by  the  deposi- 
tion of  lime  salts,  into  little  more  than  calcareous  plates.  The  chordae 
tendinese  are  often  so  contracted  that  the  papillary  muscles  appear  to 
be  inserted  directly  into  the  valve  segments. 

Valvular  insufficiency  is  an  almost  constant  accompaniment  of  the 
stenosis,  the  deformed  valves  being  incapable  of  accurate  coaptation. 
As  a  result  of  the  obstruction  to  the  flow  of  blood  from  the  auricle, 
that  chamber  becomes  dilated  and  hypertrophied.  Its  walls  rarely 
attain  a  thickness  of  more  than  half  an  inch  (1.2  cm.),  or  about  three 
times  the  normal  thickness.  The  congestion  of  the  lungs  is  extreme; 
more  so  than  in  any  other  valvular  lesion.  The  engorgement  of  the 
pulmonary  veins  and  of  the  "lesser  circulation"  in  turn  retard  the 
entrance  of  blood  from  the  heart;  the  right  ventricle  in  consequence 
becomes  hypertrophied  and  dilated,  the  tricuspid  valve  is  rendered  rela- 
tively incompetent,  and,  just  as  in  mitral  insufficiency,  the  tension  be- 
comes increased  in  the  general  venous  circulation.  The  left  ventricle, 
receiving  less  than  the  normal  supply  of  blood,  undergoes  little  or  no 
hypertrophy,  unless  incompetency  also  exists.  In  some  instances  it 
appears  abnormally  small,  owing  to  the  great  enlargement  of  the  right. 
The  total  enlargement  of  the  heart  is  not  usually  extreme.  An  ante- 
miortem  thrombus  is  commonly  found  in  the  left  auricle,  and  white  thrombi 
may  be  found  in  the  auricular  appendages.  A  globular  concretion  as 
large  as  a  walnut  ("ball  thrombus")  has  been  found  in  a  few  instances. 

Symptoms. — The  subjective  manifestations  are  much  the  same  as  in 
mitral  insufficiency,  but  slower  of  development,  and  the  pulmonary 
engorgement  is  more  extreme.  The  arterial  circulation  is  impoverished, 
while  the  venous  is  congested.  The  symptoms  after  the  failure  of  com- 
pensation are  the  same  as  those  seen  in  mitral  insufficiency,  notably, 
rapid,  irregular  action  of  the  heart,  dyspnea,  and  cyanosis.  Hemoptysis 
is  more  common.    The  remote  effects  have  been  described  on  page  336. 

Physical  Signs. — Inspection. — The  strongest  impulse  is  seen  beneath 
the  lower  portion  of  the  sternum.  In  children  the  area  may  be  abnor- 
mally prominent.     A  pulsation  is  often  seen  in  the  third  or  fourth  inter- 


VALVULAR   DISEASES    OF    THE    HEART  341 

costal  space,  near  the  left  of  the  sternum,  when  the  chest  wall  is  thin. 
The  apex  beat  cannot  always  be  recognized;  it  is  not  usually  displaced 
beyond  the  line  of  the  nipple. 

Palpation. — A  presystolic  fremitus  or  thrill  is  often  felt  in  the  fourth 
or  fifth  intercostal  space,  within  the  nipple  line.  It  is  usually  short, 
harsh,  and  distinct,  and  terminates  with  a  sharp  shock  in  the  usual 
cardiac  impulse.  When  present  it  is  pathognomonic  of  mitral  stenosis. 
The  evidences  obtained  from  inspection  are  confirmed.  The  strong 
impulse  beneath  the  sternum  and  in  the  third  and  fourth  left  interspaces 
can  be  distinctly  felt;  sometimes  there  is  also  a  distinct  impulse  in  the 
second  interspace  due  to  the  pulsation  of  the  conus  arteriosus  of  the 
right  auricle. 

Percussiou. — The  area  of  dullness  is  increased  tranversely,  but  not  nearly 
to  the  extent  seen  in  mitral  insufficiency.  In  extreme  cases  it  extends 
from  two  inches  (5  cm.)  to  the  right  of  the  sternum  to  the  nipple,  or 
a  short  distance  to  the  left  of  it,  rarely  more  than  an  inch  even  when 
incompetency  is  also  present. 

Auscultation. — The  characteristic  sign  of  mitral  stenosis,  during  the 
stage  of  compensation,  is  a  presystolic  murmur  heard  most  distinctly 
at  the  apex  or  a  short  distance  to  the  right  of  it.  This  is  usually 
a  prolonged,  rough,  purring,  or  rumbling  murmur,  heard  just  before 
the  first  sound  and  terminating  in  it.  Its  character  and  the  time  of 
its  occurrence  are  readily  understood  when  it  is  remembered  that  it  is 
produced  during  the  passage  of  the  blood  through  the  narrowed  orifice 
from  the  auricle  into  the  ventricle.  It  usually  begins  in  the  latter  half 
of  the  auricular  systole,  but  sometimes  earlier,  and  ends  at  the  first 
sound,  which  is  generally  sharp,  clear,  and  distinct.  It  is  often  audible 
over  only  a  very  limited  area. 

The  systolic  apex  murmur  not  infrequently  accompanies  the  presys- 
tolic, owing  to  the  commonly  associated  regurgitation.  It  is  usually 
low  and  indistinct,  but  it  may  be  loud  and  transmitted  to  the  axilla. 
The  pulmonary  second  sound  is  strongly  accentuated  and  sometimes 
reduplicated,  but  the  aortic  second  sound  is  generally  reduced  in  force. 
A  tricuspid  murmur  is  occasionally  heard  over  the  lower  sternal  region 
or  to  the  right  of  it  in  cases  of  long  standing,  owing  to  regurgitation 
through  that  valve. 

After  compensation  has  failed,  the  presystolic  murmur  and  thrill 
are  lost,  but  the  sharp  first  sound  and  the  shock  usually  persist.  In 
some  cases  the  irregular  action  of  the  heart  is  so  extreme  as  to  obscure 
the  auscultatory  signs. 

Diagnosis. — Mitral  stenosis  is  not  difficult  of  recognition  in  a  typical 
case,  and  the  sources  of  error  are  few.  But  during  the  failure  of  com- 
pensation, when  the  thrill  and  murmur  are  absent,  the  valvular  condi- 
tion may  be  overlooked.  Its  existence  should  be  suspected  from  the 
hypertrophy,  the  sharp  first  sound,  the  accentuation  of  the  pulmonary 
second  sound,  and  the  great  irregularity  of  the  heart's  action  in  most 
cases. 

The  Flint  murmur,  which  is  more  fully  described  under  the  head  of 
Aortic  Incompetency  (p.  345),  should  not  be  mistaken  for  that  of  mitral 
stenosis,  since  it  is  usually  confined  to  the  middle  period  of  auricular 
systole,   and  it  is  heard  only  in  association  with  the  murmur  of  aortic 


342  PRACTICE  OF  MEDICINE 

regurgitation,  a  lesion  that  is  rarely  coexistent  with  this  condition. 
The  aortic  regurgitant  murmur  is  heard  at  the  base  better  than  at  the 
apex,  and  replaces  the  second  sound  of  the  affected  valve. 

Aneurism  of  the  arch  of  the  aorta  may  be  suspected  when  the  left 
recurrent  laryngenal  nerve  is  compressed  by  the  dilated  auricle,  causing 
paralysis  of  the  vocal  cord  of  the  same  side,  but  it  can  generally  be 
excluded  by  the  absence  of  the  other  diagnostic  signs  of  aneurism  and 
the  presence  of  those  indicative  of  stenosis. 

Prognosis. — Patients  with  mitral  stenosis  often  live  many  years,  ex- 
periencing little  discomfort  except  under  the  strain  of  excessive  exertion. 
After  compensation  has  failed,  however,  the  prospect  of  relief  through 
treatment  is  less  favorable  than  in  mitral  insufficiency,  since  the  possi- 
bility of  compensation  is  greatly  limited  by  the  narrow  mitral  orifice 
and  depends  for  the  most  part  upon  the  remote  force  of  the  hypertro- 
phied  right  ventricle. 

AORTIC   INCOMPETENCY. 

Etiology. — This  form  of  valvular  lesion  ranks  next  in  frequency  to 
mitral  insufficiency.  It  is  met  with  in  about  one-third  of  all  cases, 
oftener  in  men  than  in  women,  and  generally  in  those  of  middle  age. 
It  is  most  frequently  due  to  endocarditis,  which  may  be  of  the  ulcera- 
tive form  or  a  result  of  rheumatism  or  other  infectious  disease.  The 
lesions  are  not  uniform.  They  may  be  :  (rt-)  Disease  of  the  cusps  with 
destruction  of  tissue  or  nodular  excrescences  along  their  edges,  but  in 
most  cases  there  is  a  more  uniform  sclerosis,  often  leading  to  agglutina- 
tion of  the  edges  and  partial  closure  of  the  orifice.  The  segments  are 
often  in  a  state  of  calcareous  degeneration.  (/^)  In  many  instances 
the  disease  is  a  part  of  an  arteriosclerosis  the  result  of  syphilis,  alcohol- 
ism,, or  nephritis,  (r)  The  cusps  are  sometimes  ruptured  by  violent 
muscular  effort,  as  in  lifting,  running,  or  bicycling  (the  athlete's  heart), 
but  the  valve  is  generally  in  an  abnormal  condition  from  previous  dis- 
ease at  the  time  of  rupture.  (^)  In  another  group  of  cases  the  insuf- 
ficiency is  due  to  a  dilatation  of  the  valve-ring  from  atheromatous 
disease  of  the  artery  or  the  presence  of  an  aneurism  of  the  ascending 
aorta  close  to  the  heart.  (,?)  Congenital  insufficiency  is  met  wdth  as  a 
very  rare  condition. 

Morbid  Anatomy. — The  deformity  of  the  valve  ma}'  consist  of  an  ul- 
ceration or  partial  destruction  of  the  cusps ;  a  superficial  or  deep  rent 
may  be  found  in  cases  that  have  proved  rapidly  fatal.  The  cusps  may 
be  contracted,  curled,  puckered,  or  converted  into  calcareous  plates.  A 
segment  is  sometimes  found  adherent  to  the  intima  of  the  aorta  and 
held  back  by  the  adhesion.  The  left  ventricle  is  greatly  hypertrophied 
and  in  cases  of  long  duration  it  is  sometimes  enormously  dilated  as  a 
direct  result  of  valvular  insufficiency.  With  each  ventricular  diastole  a 
part  of  the  blood  is  regurgitated  from  the  aorta  into  the  ventricle,  and 
the  hypertrophy  occurs  in  response  to  the  overdistention  that  is  thus 
produced.  The  heart  sometimes  weighs  from  40  to  50  ounces  and  has 
therefore  received  the  name  cor  bovinum,  for  it  reaches  a  greater  degree 
of  hypertrophy  and  dilatation  than  in  any  other  form  of  heart  disease. 
The  papillary  muscles  are  sometimes  flattened. 


VALVULAR  DISEASES  OF  THE  HEART  343 

Among  associated  conditions  more  or  less  constantly  observed  are  a 
thickening  of  the  edges  of  the  mitral  leaflets  and  often  a  relative  insuf- 
ficiency of  the  valve,  arising"  from  the  extreme  dilatation.  The  left 
a,uricle  generally  becomes  dilated  and  hypertrophied.  After  these  lesions 
have  become  established,  pulmonary  engorgement,  with  subsequent  hy- 
pertrophy and  dilatation  of  the  right  heart,  ensues,  in  the  same  manner 
^s  in  mitral  insufficiency.  Moderate  dilatation  occurs,  indeed,  before 
insufficiency  of  the  mitral  valve  has  been  induced.  Changes  occur,  as  a 
rule,  in  the  arterial  system  also.  The  ascending  portion  of  the  aorta 
becomes  dilated,  and  sclerotic  or  atheromatous  disease  of  the  intima 
is  commonly  produced.  Following  these  changes  the  orifices  of  the  coro- 
nary arteries  often  become  obstructed,  or  these  vessels  may  also  undergo 
atheromatous  change.  The  supply  of  blood  which  they  receive  is  dimin- 
ished by  the  reduction  of  the  pressure  in  the  aorta  during  the  ven- 
tricular systole,  the  period  in  which  they  receive  their  supply.  This  in 
turn  impairs  the  nutrition  of  the  heart  muscle  and  induces  fatty  or 
parenchymatous  degeneration  or  interstitial  myocarditis,  and  thus 
hastens  the  dilatation  and  ultimate  failure  of  the  heart.  The  pain  and 
occasional  attacks  of  angina  are  attributed  to  changes  in  the  nerves 
of  the  heart  or  to  pressure  upon  them  by  the  sclerotic  tissue  associated 
with  the  interstitial  myocarditis.  A  more  or  less  general  arteriosclerosis 
is  commonly  found  in  the  vessels  thoughout  the  body,  as  a  result  of  the 
sudden  strain  thrown  upon  them  by  the  forcible  contractions  of  the 
hvpertrophied  ventricle.  It  is  a  remarkable  fact,  however,  that  in  some 
instances,  particularly  in  rheumatic  cases,  although  there  have  been 
evidences  during  life  of  enormous  distention  of  the  arch  of  the  aorta, 
innominate,  and  right  carotid,  these  vessels  are  found  to  be  almost 
perfectly  normal  and  free  from  dilatation  after  death.  A  greater  or  less 
degree  of  stenosis  sometimes  accompanies  the  insufficiency,  but  it 
is  not  so  uniformly  present  as  in  the  corresponding  lesion  of  the  mitral 
valve. 

Symptoms. — This  disease  often  exists  for  a  great  length  of  time  with- 
out producing  definite  disturbances.  Among  the  earliest  symptoms 
manifested,  but  often  referred  to  some  other  cause,  are  headache,  flashes 
of  light,  tinnitus  and  vertigo  or  faintness  upon  rising  suddenly.  Slight 
■exertion  often  causes  palpitation  and  shortness  of  breath,  and  this  may 
be  accompanied  with  distress  or  actual  pain  in  the  cardiac  region.  Pc'iin 
is  a  comparatively  early  symptom  in  some  cases.  It  may  be  a  dull 
ache  confined  to  the  precordial  region,  or  sharp  and  spasmodic,  often 
radiating  to  the  left  shoulder  and  sometimes  down  the  arm  or  up  the 
neck.  It  seldom  radiates  to  the  right  side.  Topical  ^lttacks  of  angina 
pectoris  occur  in  some  cases. 

After  failure  of  compensation,  symptoms  of  a  more  definite  character 
are  induced.  Dyspnea  is  often  a  most  marked  feature;  it  is  usually 
worst  at  night  and  compels  the  patient  to  sleep  with  his  head  high,  oi 
sitting  in  a  chair.  The  sleep  is  disturbed  by  dreams  and  nervous  starts 
or  sensations  of  suff'ocation  more  frequently  than  in  any  other  form 
•of  valvular  lesion.  Cough  is  a  common  symptom,  due  to  the  engorge- 
ment of  the  lungs,  but  hemoptysis  and  cyanosis  are  seldom  observed 
in  an  uncomplicated  case.  The  patient  is  usually  anemic.  The  blood- 
count  may   fall  below  3,000,000  in   the  c.mm.     Edema    of   the    ankles 


344  PRACTICE  OF  MEDICINE 

generally  supervenes;  at  first,  perhaps,  as  a  result  of  the  anemia,  later 
as  a  result  of  the  failing  of  the  circulation.  General  dropsy  rarely 
ensues  in  the  absence  of  extreme  incompetency  of  the  mitral  valve  as  an 
associated  lesion. 

Intercurrent  attacks  of  acute  endocarditis  are  not  unusual  and  often 
lead  to  a  hastily  fatal  termination  of  the  disease.  Embolism  is  also  a 
frequent  complication.  It  is  announced  by  sudden  pain,  perhaps  asso- 
ciated with  tenderness  in  the  affected  region,  as  in  the  spleen.  Hema- 
turia develops  when  the  kidney  is  the  seat  of  the  lodgment,  and  paral- 
ysis when  the  brain  is  involved.  The  closing  weeks,  perhaps  months^ 
of  the  patient's  life  are  most  distressing.  Great  restlessness,  delirium,, 
and  moroseness  are  commonly  developed.  The  patient  sometimes  be- 
comes acutely  insane  and  he  may  attempt  suicide.  To  what  extent 
such  maifestations  are  a  result  of  the  valvular  condition  and  to  what 
extent  they  may  be  referred  to  an  associated  uremia  in  different  cases, 
has  not  been  determined.  Sudden  death  occurs  more  frequently  in  this 
than  in  any  other  form  of  valvular  disease. 

Physical  Signs. — Inspection. — The  cardiac  impulse  is  strong  and  heaving. 
The  apex  beat  is  displaced  to  the  left,  but  seldom  beyond  the  anterior 
axillary  line.  It  may  be  as  low  as  the  sixth  or  seventh  intercostal 
space.  The  precordial  space  sometimes  appears  prominent,  especially 
in  children.  The  vessels  of  the  neck  throb,  and  in  extreme  cases  pulsa- 
tion of  the  superficial  vessels  of  the  entire  upper  part  of  the  body,  es- 
pecially in  the  suprasternal  notch,  becomes  visible.  Ophthalmoscopic 
examinations  reveal  similar  pulsation  of  the  retinal  vessels. 

Palpation. — A  forcible  impulse  is  felt,  except  in  the  late  stages  of 
the  disease,  when  it  becomes  softer  and  wavy.  There  is  sometimes  a 
distinct  pulsation  of  the  entire  precordial  region,  and  sometimes  also 
in  the  second  right  intercostal  space,  due  to  the  pulsation  of  the  aorta. 
A  depression  of  one  or  more  of  the  left  interspaces,  between  the  sternum 
and  mammary  line,  is  occasionally  perceptible  during  systole.  A  dias- 
tolic thrill  can  occasionally  be  felt  over  the  base. 

The  pulse  of  aortic  incompetency  is  characteristic.  The  impact  is 
strong  and  jerky,  often  apparently  full,  but  it  immediately  collapses 
under  the  finger..  The  forcible  impulse  is  due  to  the  strong  contraction 
of  the  ventricle,  which  throws  the  blood  into  the  arteries  with  much 
force,  but  the  regurgitation  permits  the  blood  to  fall  back  almost  in- 
stantly. This  peculiarity  can  sometimes  be  better  recognized  when  the 
hand  is  held  high  above  the  head  during  the  palpation  of  the  pulse, 
thus  favoring  the  recoil  after  the  first  impulse.  On  account  of  this 
feature,  the  pulse  is  often  referred  to  as  the  water-hammer  pulse.  An- 
other distinctive  feature  of  the  pulse  is  that  it  is  delayed,  a  perceptible 
interval  elapsing  between  the  systole  of  the  heart  and  the  radial  impulse, 
particularly  in  the  advanced  stage  of  the  disease.  Palpation  of  the 
vessels  of  the  neck  reveals  a  similar  pulsation  and  sometimes  a  thrill. 
The  pulsation  and  thrill  commonly  felt  i^  the  suprasternal  notch  in  this 
disease  occasionally  lead  to  the  erroneous  diagnosis  of  aortic  aneurism. 
A  venous  pulsation  is  occasionally  observed,  but  it  is  seldom  so  strong 
as  to  be  recognized  on  palpation.  An  arterial  pulsation  of  the  liver  is 
occasionally  noted,  and  less  frequently  that  of  the  spleen.  A  capillary 
pulsation  is  not  infrequently  obtained  either  by  gently  compressing  the 


VALVULAR  DISEASES  OF  THE  HEART  345 

finger-nails  or  by  drawing  the  finger-nail  across  the  forehead.  Be-neath 
the  compressed  nail  or  at  the  margin  of  the  hyperemic  line  an  alternat- 
ing flush  and  paling  can  be  seen.  It  is  not,  however,  fully  pathogno- 
monic of  aortic  insufiiciency. 

Peraission  reveals  a  great  increase  of  the  area  of  dullness,  greater  in 
extreme  cases  than  in  any  other  valvular  lesion.  Its  direction  is  more 
particularly  downward  and  outward  to  the  left. 

Auscultation. — The  murmur  of  this  lesion  is  one  of  soft,  blowing, 
sometimes  musical  quality,  long  in  duration,  and  heard  with  greatest 
intensity,  as  a  rule,  at  the  base  of  the  heart,  in  the  middle  of  the  ster- 
num opposite  the  third  costal  cartilage,  or  along  the  entire  right  side  of 
the  sternum  from  the  second  cartilage  to  the  xiphoid.  The  murmur  may 
be  harsh  when  the  cusps  have  become  calcified  or  in  cases  of  traumatic 
rupture  of  a  segment.  The  second  sound  may  persist,  but  it  is  often 
entirely  replaced  by  the  murmur.  A  short,  soft  systolic  murmur  is 
sometimes  heard  at  the  base,  but  in  most  cases  the  first  sound  is  clear 
and  distinct  until  late.  When  a  partial  stenosis  accompanies  the  in- 
sufficiency, and  especially  when  the  cusps  are  adherent  along  a  part  of 
their  edges,  a  sharp,  rough  systolic  murmur  is  heard.  It  must  not  be 
regarded  as  a  feature  of  the  incompetency,  but  as  a  comparatively  fre- 
quent complication.  In  many  cases  no  abnormal  sound  is  heard  at  the 
apex,  but  when  relative  insufficiency  of  the  mitral  valve  has  been  induced 
an  apical  systolic  murmur  accompanies  the  diastolic  which  is  heard  at 
the  base.  This  murmur  should  not  be  confounded  with  the  interesting 
bruit  sometimes  heard  at  the  apex  and  known  as  the  Flint  murinu7\ 
This  is  a  more  or  less  distinct  rumbling  sound,  described  as  echoing  in 
qualit}-,  usually  occurring  at  the  middle  of  diastole ;  sometimes  it  is  more 
immediately  presystolic,  and  heard  only  at  the  apex.  It  is  recognizable 
in  about  half  the  cases  of  aortic  incompetency.  It  is  less  distinct  than 
the  presystolic  murmur  of  mitral  stenosis,  although  it  is  virtually  a  mur- 
mur of  that  character.  It  is  attributed  to  the  forcible  impact  of  the 
regurgitated  blood  upon  the  large  anterior  curtain  of  the  mitral  valve, 
possibly  causing  it  to  interfere  with  the  simultaneous  entrance  of  blood 
from  the  left  auricle.  It  is  not  accompanied  by  the  accentuation  of  the 
first  sound,  and  it  is  always  associated  with  the  murmur  of  aortic  in- 
sufficienc3\  A  double,  to-and-fro  murmur  can  sometimes  be  heard  by 
auscultation  over  the  carotid  and  femoral  arteries. 

Diagnosis. — In  the  ventricular  hypertrophy  of  chivnic  neplwitis  a  mur- 
mur with  greatest  intensity  at  the  base  may  be  heard,  but  the  second 
sound  is  distinct  and  accentuated,  and  the  urinar}^  examination  reveals 
the  condition  of  the  kidneys.  The  hypertrophy  is  usually  moderate. 
The  differentiation  can  be  further  established  by  cryoscopy.  The  freezing- 
point  of  the  urine  is  high,  sometimes  above  the  normal  limit,  — 1-30° 
C,  in  renal  disease,  but  below' — 2.20°  C.  when  the  heart  is  affected. 

Anemic  nuii-murs  are  heard  at  the  base,  but  they  are  usually  softer,  of 
shorter  duration,  and  unaccompanied  with  hypertroph}^  No  thrill  can  be 
felt,  and  the  arterial  pulsations  are  absent ;  a  venous  purring  can  some- 
times be  heard  in  the  cervical  veins. 

The  prognosis  depends  upon  the  extent  of  the  insufficiency,  the  char- 
acter of  its  cause,  and  the  presence  or  absence  of  myocardial  changes 
and  other  complications.    Cases  due  to  endocarditis  arc  more  favorable 


'346  PRACTICE  OF  MEDICINE 

to  life  than  those  due  to  arteriosclerosis.  After  degeneration  of  the 
heart  muscle,  compensation  rapidly  fails;  and  after  other  valvular  lesions 
ensue,  the  downward  progress  of  the  case  becomes  more  rapid. 

AORTIC    STENOSIS. 

Etiology. — Narrowing  of  the  aortic  orifice  is  a  comparatively  rare 
■form  of  valvular  lesion,  except  when  it  is  associated  with  aortic  incom- 
petency. It  is  generally  due  to  the  encroachment  of  atheromatous 
disease  of  the  aorta  upon  the  valve  ring  or  segments.  It  may,  however, 
result  from  a  chronic  endocarditis  following  the  acute  form  of  the  dis- 
ease, or  it  may  accompany  the  arteriosclerosis  of  advanced  life.  It  is  a 
disease  of  the  aged. 

Morbid  Anatomy. — The  cusps  of  the  valve  are  usually  adherent  to  a 
variable  extent  along  their  margins ;  they  may  be  thickened,  more  or  less 
distorted,  and  calcified.  Sometimes,  on  the  other  hand,  they  show  little 
or  no  change  beyond  the  adhesion  of  their  margins,  and  form  a  rather 
thin  membrane,  the  aortic  surface  of  which  still  shows  the  primitive 
raphe  separating  the  sinuses  of  Valsalva.  When  they  retain  this  ap- 
pearance the  condition  is  sometimes  regarded  as  congenital.  When  there 
is  much  deformity,  the  valves  are  incompetent.  Vegetations  and  deposits 
of  fibrin  are  sometimes  present.  The  left  ventricle  becomes  greatly 
hypertrophied  by  the  increased  work  thrown  upon  it,  but  there  is  little 
or  no  enlargement  of  the  chamber  (concentric  hypertrophy).  Dilatation 
is  encountered  only  as  a  very  late  change.  After  it  supervenes,  however, 
the  other  lesions  constituting  the  "vicious  circle"  are  developed,  includ- 
ing relative  insufficiency  of  the  mitral  valve,  dilatation  of  the  left  auricle, 
pulmonary  engorgement,  hypertrophy  and  dilatation  of  the  right  ventri- 
cle, and,  finally,  general  venous  engorgement. 

Symptoms. — Many  patients  remain  free  from  subjective  symptoms  for 
a  great  number  of  years,  as  long,  in  fact,  as  the  obstruction  is  compen- 
sated for  by  the  strong  action  of  the  hypertrophied  ventricle.  The 
manifestations  are  generally  due  to  the  diminution  of  the  blood  supply 
to  the  brain,  notably,  vertigo  and  faintness.  After  dilatation  has  oc- 
curred and  the  compensation  has  been  lost,  the  usual  symptoms  make 
their  appearance. 

Physical  Signs. — Inspection. — There  may  be  no  recognizable  impulse, 
especially  in  old  men  with  firm  chest-walls  and  emphysematous  lungs. 
The  apex  beat,  when  recognizable,  is  feeble,  as  a  rule,  but,  with  increasing 
hypertrophy  of  the  left  ventricle,  it  becomes  more  prominent,  and  it  is 
then  displaced  outward  and  downward. 

Palpation. — The  thrill  is  more  commonly  felt  in  this  than  in  any 
other  valvular  lesion.  It  is  usually  felt  over  the  base  and  may  be  well 
marked.  The  apex  beat  cannot  always  be  felt,  and,  when  recognizable,  it 
varies  in  force  and  position  with  the  h3^pertrophy.  The  pulse  is  small, 
firm,  and  of  only  moderate  fullness. 

Percussion. — The  area  of  dullness  is  not  usually  extensive.  It  may  be 
increased  in  a  downward  and  outward  direction,  but  it  is  often  obscured 
by  the  presence  of  pulmonary  emphysema. 

Auscultation. — The  typical  sign  of  aortic  stenosis  is  a  harsh,  rough 
systolic  murmur,  most  intense  at  the  base,  but  transmitted  to  the  great 


VALVULAR  DISEASES  OF  THE  HEART  347 

vessels.  A  musical  tone  is  sometimes  heard.  The  second  sound  is  gen- 
erally absent ;  sometimes  it  is  replaced  by  a  murmur  of  regurgitation 
when  the  valvular  defect  is  so  great  as  to  cause  incompetency.  Very 
similar  to  this  murmur  is  the  bruit  caused  by  hemic  conditions  or  that 
caused  by  the  passage  of  the  blood  over  a  roughened  orifice  or  cal- 
careous plates  in  the  wall  of  the  aorta  near  the  valve.  After  the  com- 
pensation has  failed,  the  murmur  becomes  softer  and  less  distinct. 

Diagnosis. — The  condition  is  not  usually  difficult  of  diagnosis,  and 
the  only  source  of  error,  as  a  rule,  is  the  adventitious  murmur  just  re- 
ferred to.  This  can  be  excluded  by  the  hypertrophy  of  the  left  ventricle 
and  the  small,  firm  pulse.  A  distinct  murmur,  especially  if  musical  and 
heard  in  this  region,  is  generally  due  to  aortic  stenosis. 

The  prognosis  depends  upon  the  condition  of  the  valve.  Uncompli- 
cated stenosis  is  not  incompatible  with  fair  health  so  long  as  compen- 
sation is  maintained,  but,  associated  with  regurgitation  and  after  com- 
pensation has  failed,  the  consequences  are  more  serious. 

TRICUSPID    INSUFFICIENCY. 

Etiology. — The  tricuspid  valve  is  seldom  incompetent  as  a  result  of 
disease,  and  a  regurgitation  of  blood  through  it  is  commonly  a  result 
of  relative  insufficiency  due  to  dilatation  of  the  right  ventricle  following 
lesions  of  other  valves,  or  obstruction  of  the  pulmonary  circulation  in 
emphysema  or  interstitial  pneumonia. 

Symptoms. — A  systolic  pulsation  is  transmitted  to  the  veins  of  the 
neck  as  a  result  of  the  regurgitation  of  blood  into  the  auricle  with 
each  contraction  of  the  ventricle.  This  pulsation  is  distinctly  visible,  as 
a  rule,  in  the  right  jugular,  sometimes  also  in  the  subclavian  and  axillary 
veins.  When  the  valves  of  the  veins  remain  intact  it  may  amount  to 
only  a  slight  wavy  vibration.  The  pulsation  is  often  transmitted  to 
the  liver ;  the  pulsation  of  the  organ  can  be  felt,  in  bimanual  palpation, 
with  each  systole;  very  rarely,  it  can  be  seen.  A  systolic  murmur 
can  be  heard  over  the  lower  sternal  region  and  to  the  right,  sometimes 
as  far  as  the  axillary  line,  but  often  over  only  a  very  limited  area. 
It  is  generally  soft  in  quality  and  variable  in  pitch.  Another  marked 
feature  in  many  cases  is  an  extreme  distention  of  the  veins  of  the  upper 
part  of  the  body  when  the  patient  strains  or  coughs.  The  pulsation 
of  the  veins  is  distinctly  visible  during  this  distention.  Percussion  shows 
an  increased  area  of  dullness,  especiall}'  to  the  right  of  the  sternum. 
The  symptoms  belonging  strictly  to  the  condition  are  obscured  in  most 
cases  by  those  of  the  underlying  disease.  The  congestion  of  the  organs 
is  general,  however,  and  that  of  the  kidneys  is  often  a  distinct  feature 
of  the  disease.  Anasarca  develops  toward  the  close,  affecting  the  face 
and  upper  extremities  more  than  it  does  in  other  valvular  lesions. 

Diagnosis. — This  is  clear  in  the  presence  of  hypertrophy  of  the  right 
ventricle,  with  venous  engorgement  and  pulsation  and  a  systolic  mur- 
mur heard  with  greatest  intensity  in  the  lower  sternal  region. 

TRICUSPID    STENOSIS. 

Etiology. — This  is  a  rare  lesion  except  in  congenital  cases,  and  these 
are  often  associated  with  other  defects  that  are  incompatible  with  life. 


348  PRACTICE  OF  MEDICINE 

It  may,  however,  be  acquired.  It  then  occurs  in  adult  life,  and  fully  80 
per  cent  of  recorded  cases  have  been  seen  in  women.  It  is  seldom  the 
only  valvular  lesion  present ;  in  most  cases  the  mitral  or  both  the  mitral 
and  aortic  valves  are  defective.  In  most  cases,  too,  the  tricuspid  lesion 
is  a  result  of  one  of  the  other  lesions. 

Physical  Signs.— A.  presystolic  thrill  has  been  observed  in  some  in- 
stances. The  dullness  is  somewhat  increased,  particularly  to  the  right 
of  the  sternum.  A  pre_systolic  murmur  is  heard  at  the  base  of  the 
xiphoid  cartilage  or  just  at  the  right  of  it.  The  patient  is  generally 
cyanotic,  sometimes  extremely  and  constantly  so.  When  the  condition 
is  thus  extreme,  an  intense  general  dropsy  often  ensues.  The  prognosis 
is  always  exceedingly  grave,  owing  to  the  impossibility  of  relief  through 
any  such  change  as  compensatory  hypertrophy, 

PULMONARY  VALVE   LESIONS. 

Functional  Murmurs.— A  soft  blowing  murmur  is  very  often  heard 
in  auscultation  over  the  second  left  intercostal  space  in  children  and 
sometimes  in  adults  in  ill  health,  especially  when  the  patient  is  lying 
down.  It  may  be  heard  also  in  anemia  or  after  slight  exertion  during 
convalescence  from  any  of  the  acute  fevers.  But  it  is  heard  also  in 
some  individuals  in  good  health  with  thin  chest-walls,  during  expiration. 
It  is  purely  functional  and  of  little  significance. 

Pulmonary  insufficiency  is  an  exceedingly  rare  condition  sometimes 
resulting  from  congenital  malformation,  as  when  the  segments  are  agglu- 
tinated. It  may  result  from  endocarditis.  It  has  been  suggested  also 
that  a  "  safety  valve"  leakage  sometimes  occurs  when  the  pulmonary 
vessels  become  engorged.  The  murmur  is  diastolic  and  is  heard  most 
distinctly  at  the  second  left  intercostal  space.  The  right  ventricle 
becomes  hypertrophied  and  dilated.  The  aortic  sounds  and  the  radial 
pulse  remain  normal.  The  bruit  is  often  distinguished  with  much  difii- 
culty  from  that  of  aortic  insufficiency,  except  by  the  absence  of  the 
usual  results  of  that  lesion. 

Pulmonary  stenosis  is  one  of  the  most  important  congenital  defor- 
mities of  the  heart.  It  may,  however,  be  encountered  in  adult  life  as  a 
result  of  endocarditis  or  atheroma.  When  congenital  it  generally  con- 
sists of  an  agglutination  of  the  margins  of  the  valve  segments  to  such 
an  extent  as  to  greatly  diminish  the  size  of  the  orifice.  The  stenosis 
is  generally  compensated  for  by  an  incompleteness  of  the  ventricular 
septum  or  patency  of  the  foramen  BotalH.  Tricuspid  stenosis  is  some- 
times associated  with  the  lesion.  The  diagnosis  is  difficult.  The  right 
heart  is  generally  hypertrophied,  and  a  systolic  murmur  can  sometimes 
be  heard  in  the  left  intercostal  space.  It  may  be  transmitted  to  the 
right,  but  never  along  the  great  vessels,  as  is  that  of  aortic  stenosis, 
with  which  it  might  otherwise  be  confused.  The  pulmonary  second 
sound  is  feeble  or  quite  inaudible. 

Association  of  Valvular  Lesions.— Valvular  lesions  are  generally  asso- 
ciated in  the  following  order  of  frequency:  (i)  Mitral  and  aortic 
lesions;  in  children  mitral  and  aortic  insufficiency  are  most  frequently 
combined;  in  adults  mitral  insufficiency  combines  with  aortic  stenosis; 
(2)   mitral   and  tricuspid  lesions;    (3)   mitral,    aortic,    and    tricuspid; 


VALVULAR  DISEASES  OF  THE  HEART  349 

(4)    insufificiency    or  stenosis  of  the  aortic  valves  is    more    frequently 
associated  with  mitral  insufificiency  than  with  mitral  stenosis. 

Prognosis  of  Valvular  Lesions. — The  prognosis  in  all  valvular  lesions 
depends  for  the  most  part  upon  the  extent  to  which  compensation  is 
maintained.  This  may  be  estimated  from  the  degree  of  dilatation  that 
is  present  and  from  the  character  of  the  heart's  action.  The  prognosis 
is  more  favorable  when  compensation  can  be  brought  about  by  treat- 
ment, but  it  is  then  less  favorable  than  when  it  is  spontaneous,  and 
before  dilatation  has  occurred.  Age  is  also  an  important  factor  in  prog- 
nosis. Children  are  generally  poor  subjects  of  valvular  lesion,  but  com- 
pensation sometimes  develops  at  puberty,  and  with  care  life  may  then 
be  greatly  prolonged,  providing  the  constitution  be  vigorous  and  the 
patient  free  from  attacks  of  rheumatism,  influenza,  or  other  infection. 
Women  generally  tolerate  valvular  lesions  better  than  men,  probably 
because  of  less  exposure  to  overexertion  or  other  influence  that  dis- 
turbs compensation.  The  prognosis  is  impaired  by  all  acute  infections, 
as  well  as  by  syphilis,  alcoholism,  the  arthritic  diathesis,  chronic  pul- 
monary and  renal  disease.  The  prognosis  of  the  different  lesions  has 
been  referred  to  under  each  heading. 

Treatment  of  Valvular  Lesions. — Stage  of  Compensation. — i.  The  admin- 
istration of  cardiac  remedies  to  a  patient  whose  heart  is  acting  regu- 
larly, with  full  compensation  of  the  defect,  is  one  of  the  most  serious 
errors  that  can  be  committed.  Nothing  is  then  required  but  to  guard 
the  patient  against  the  influences  that  are  likely  to  disturb  the  action 
of  the  heart.  It  is  often  injudicious  to  inform  him  of  his  condition, 
especially  when  it  is  discovered  accidentally  during  an  examination.  On 
the  other  hand,  the  discovery  may  prove  to  be  a  valuable  one  to  the 
patient  by  enabling  him  to  avoid  excesses  that  tend  to  hasten  the  loss 
of  compensation.  Under  all  circumstances  the  physician  should  remember 
that  a  bruit  does  not  always  signify  a  valvular  disease,  and  he  should  be 
absolutely  sure  of  the  correctness  of  his  diagnosis  before  divulging  it. 
The  temperament  of  the  patient  should  also  be  considered  in  connection 
with  the  character  of  the  lesion.  As  a  rule,  he  should  be  given  the  assur- 
ance that  valvular  disease  of  the  heart  is  not  necessarily  fatal  and  that 
the  duration  of  his  life  depends  to  a  great  extent  upon  the  manner  in 
which  he  conducts  himself.  He  should  be  instructed  with  regard  to  the 
influences  which  are  most  harmful  in  his  condition.  A  practical  man 
leading  an  active  life  or  engrossed  with  much  business  care  and  worry 
should  be  frankly  told  that  he  has  reached  the  time  for  rest,  especially 
when  he  is  suffering  from  an  aortic  lesion.  A  nervous  person  with  a  less 
serious  defect  will  often  be  moved  to  unnecessary  precaution  and  con- 
finement by  the  merest  hint  that  he  has  a  heart  lesion.  It  is  not  usually 
necessary  or  advisable  to  forbid  all  activity;  the  patient  should  rather 
be  instructed  to  take  such  moderate  outdoor  exercise  as  he  can  endure 
without  disturbing  the  rhythm  of  the  heart,  as  indicated  by  palpitation, 
dyspnea,  or  precordial  pain.  Any  exertion  or  excitement  that  disturbs 
the  regularity  of  the  heart's  action  must  be  avoided.  The  diet  need 
not  be  restricted,  as  a  rule,  except  so  far  as  to  avoid  overeating  and 
the  ingestion  of  indigestible  articles  likely  to  cause  flatulency.  Alcohol 
and  tobacco  should,  as  a  rule,  be  interdicted. 

2.   Stage  of  Lost  Compensation.— \.o%%  of  compensation  is  sometimes  so 


350  PRACTICE  OF  MEDICINE 

suddenly  fatal  as  to  afford  no  opportunity  for  treatment.  It  is  gen- 
erally gradual,  however,  and  may  be  relieved  unless  it  has  been  too 
long  disregarded  by  the  patient.  The  heart  must  be  given  rest.  This 
can  be  accomplished  by  confining  the  patient  to  bed  for  a  week  or  ten 
days,  thus  relieving  it  of  unnecessary  work.  In  some  cases  this  of  itself  • 
is  sufficient  to  re-establish  compensation.  It  is  not  always  possible, 
and  indeed  not  always  necessary,  to  secure  absolute  regularity  of  action, 
particularly  in  mitral  lesions.  Regularity  is  more  desirable  in  aortic 
disease,  since  irregularity  here  is  generally  significant  of  failing  com- 
pensation. In  severe  cases  associated  with  cardiac  dilatation,  when  the 
dyspnea  is  urgent  and  accompanied  with  cyanosis,  venesection  affords 
the  promptest  relief  in  cases  showing  extreme  venous  engorgement. 
Purgation  acts  in  a  similar  manner,  but  it  is  slower.  The  regular  action 
of  the  bowels  is  important  in  all  cases. 

Medicinal  Treatment. — Heart  tonics  should  be  employed  in  most  cases 
to  assist  in  restoring  compensation,  or  to  maintain  it  when  restored 
through  rest.  They  should  not  be  used  beyond  the  quantity  required 
to  secure  the  desired  result.  Digitalis  is  universally  employed  and 
can  be  relied  upon  to  maintain  its  action  for  many  years  in  some 
cases.  A  half-ounce  (15.0)  of  the  fresh  infusion  or  TT|,xto  xx  (0.6 — 1.2) 
of  a  good  tincture  should  be  given  every  three  or  four  hours  until  the 
heart's  action  has  become  full  and  regular.  Then  the  quantity  can 
generally  be  reduced  to  half  the  original  amount  or  less.  When  dropsy 
is  present,  however,  the  full  dose,  if  tolerated  by  the  stomach,  should 
be  continued  until  the  edema  has  disappeared,  and  in  cases  of  this  char- 
acter it  is  often  necessary  to  maintain  the  dosage  throughout  the  re- 
mainder of  the  patient's  life.  It  should  be  employed  in  all  cases  of  fail- 
ing compensation  of  whatever  character,  but  theoretically  at  least  it 
should  be  given  with  greater  caution  in  cases  of  stenosis  than  in  those 
of  regurgitation.  The  only  ill-effect  that  is  usually  observed  in  the 
use  of  digitalis  is  the  production  of  nausea  and  vomiting  in  some  cases, 
a  symptom  which  quickly  subsides  upon  withdrawal  of  the  drug.  When 
persistent  vomiting  is  induced,  tr.  strophanthus,  Tl^vto  viij  (0.3 — 0.5),  may 
sometimes  be  employed  in  its  stead,  but  it  does  not  always  fully  replace 
it.  Strychnin  is  often  of  great  benefit  in  giving  strength  to  the  heart 
muscles  and  may  be  employed  in  connection  with  the  digitalis ;  occasion- 
ally it  can  be  used  as  a  substitute  for  digitalis.  When  anemia  is  a 
marked  feature,  as  it  so  often  is  in  aortic  incompetency,  iron  or  arsenic 
should  be  given  in  full  doses. 

Treatment  of  Special  Symptoms.— i.  Djspnea.— The  chest  should  be 
carefully  examined  in  order  to  determine  whether  the  dyspnea  be  due 
to  the  cardiac  incompetency  or  to  hydrothorax  or  pulmonary  edema. 
When  hydrothorax  is  present,  the  fluid  should  be  withdrawn  by  aspira- 
tion as  often  as  it  becomes  excessive.  The  pulmonary  edema  may  some- 
times be  relieved  by  purgation  and  diuresis,  and  held  in  check  by  full 
doses  of  digitalis  and  strychnin.  Cupping  the  chest  may  prove  bene- 
ficial. For  the  dyspnea  and  restlessness  at  night  there  is  no  better 
remedy  than  morphin,  gr.  yg  (0.008),  or  codein,  gr.  ]4  (0.016).  Glonoin 
often  affords  prompt  relief  in  cases  in  which  the  arterial  tension  is- 
high,  but  it  must  generally  be  given  at  short  intervals  and  in  increas- 
ing doses  in  order  to  produce  more  than  transitory  effects.     The  par- 


HYPERTROPHY  OF  THE  HEART  35r 

oxysmal  dyspnea  (cardiac  asthma)  sometimes  yields  to  the  compound 
spirit  of  sulphuric  ether,  3  ss  to  j  (1.8 — 3.6),  administered  in  cold  water 
and  repeated  in  an  hour  if  necessary.  Potassium  bromid  is  also  useful 
in  these  cases.  Dyspnea  due  to  associated  bronchitis  or  emphysema 
in  elderly  persons  calls  for  special  treatment  of  those  conditions. 

2.  Palpitation  and  Angina. — In  cases  of  excessive  dilatation,  an  ice-bag" 
applied  to  the  cardiac  region  often  affords  relief  to  both  these  symp- 
toms. Tr.  aconite  may  be  employed  to  regulate  the  heart's  action 
and  is  sometimes  better  than  digitalis,  especially  in  aortic  incompetency. 
It  should  be  given  in  doses  of  gtt.  ij  or  iij  every  two  or  three  hours. 
Nitroglycerin  may  prove  beneficial.  Potassium  iodid,  gr.  x  (0.60)  t.  i. 
d.,  relieves  the  pain  in  some  cases.  Potassium  bromid  and  elixir  of 
ammonium  valerianate  are  also  of  service;  but  when  the  pain  is  severe, 
morphin  (gr.  ^;  0.016)  with  atropin  (gr.  1-120;  0.0005)  should  be 
administered  hypodermically. 

3.  Edema. — The  patient  should  be  placed  upon  a  dry  diet,  and  an 
effort  made  to  reduce  the  edema  with  hydragogue  cathartics.  The  circu- 
lation should  be  maintained  by  full  doses  of  digitalis,  and  the  action  of 
the  kidneys  further  stimulated  with  mild  diuretics — potassium  bitartratc, 
citrated  caffein  or  sodium  and  theobromin  salicjdate.  Calomel  in  doses 
of  gr.  i-io  (0.006)  is  an  excellent  diuretic  in  cardiac  cases,  but  it  must 
be  discontinued  as  soon  as  its  action  becomes  apparent.  When  the 
edema  of  the  lower  extremities  becomes  extreme,  it  is  better  to  puncture 
the  skin  than  to  allow  it  to  rupture,  although  the  necessity  should  be 
prevented,  if  possible,  by  bandaging  with  flannel.  The  legs  should  be 
bathed  with  an  antiseptic  solution  before  the  punctures  are  made  and 
at  regular  intervals,  morning  and  evening,  thereafter.  In  hospitals  the 
patient  should  be  isolated  in  order  to  protect  him  from  erysipelas  or 
other  infection  of  the  wounds. 

4.  Insomnia. — Sleeplessness  often  calls  for  special  treatment.  In  some 
cases  the  bromids  with  valerian  or  camphor  induce  quiet  sleep.  Trional 
in  a  single  dose  of  gr.  xx  or  xxx  (1.30  to  2.0)  before  retiring  may 
be  tried  when  they  fail.  Paraldehyd,  amylene  hydrate,  and  urethane  are 
also  employed,  but  their  action  is  uncertain.  Morphin  fails  to  induce 
sleep  in  some  cases.  The  insomnia  often  subsides  with  the  restoration 
of  compensation. 

5.  Hemorj'hage  from  the  nose,  lungs,  stomach,  or  uterus  requires- 
prompt  treatment.  Opium  is  always  indicated,  but  ergot,  astringents, 
and  styptics  are  generally  useless.  In  other  respects  the  treatment  is- 
the  same  as  that  of  hemorrhage  from  the  same  sources  in  other  con- 
ditions.   The  warm  salt  infusion  must  sometimes  be  resorted  to. 

HYPERTROPHY  OF  THE  HEART. 

ENLARGEMENT  OF  THE   HEART. 

Definiiion. — An  enlargement  of  the  heart  due  to  increased  thickness 
of  its  walls.  The  condition  may  be  general,  but  is  usually  confined  to 
one  or  more  chambers,  more  commonly  to  the  ventricles.  There  may 
be  simple  hypertrophy  or  hypertrophy  with  dilatation  (eccentric  hyper- 
trophy) ;  one  chamber  may  be  hypertrophied  and  another  dilated.   "  Con- 


352  PRACTICE  OF    MEDICINE 

centric  hypertrophy"  is  a  term  now  seldom  employed  to  describe  thick- 
ening of  the  walls  with  apparent  diminution  of  capacity,  probably  due 
in  all  cases  to  post-mortem  contraction.  Simple  hypertrophy  is  a  little 
more  frequently  seen  in  the  left  ventricle  than  in  the  right. 

Etio/ogy.— The  muscle  of  the  heart,  like  any  other  striped  muscle, 
responds  to  increased  exercise  by  undergoing  hypertrophy,  becoming 
larger  and  stronger.  Hypertrophy  is  in  all  cases  a  result  of  overwork, 
and  it  is  often  favored,  no  doubt,  by  overstimulation,  especially  with 
alcohol,  while  working  to  excess.  The  immediate  causes  of  hypertrophy 
of  the  right  and  left  ventricles  are  sufficiently  different  to  receive  separate 
consideration  : 

Hypertrophy  of  the  left  ventricle,  with  or  without  general  enlargement 
of  the  heart,  results  from  :  (i)  Prolonged  or  habitual  muscular  exercise, 
as  in  athletes.  Excessive  hypertrophy  is  seldom  due  to  this  cause 
alone.  (2)  From  such  conditions  of  the  heart  itself  as  (<x)  aortic  stenosis 
or  insufficiency;  (Ji)  mitral  incompetency;  (^  pericardial  adhesions; 
(^)  interstitial  myocarditis;  (<?)  overactivity  or  palpitation  due  to 
nervous  disease,  as  in  exophthalmic  goiter,  or  to  toxemia,  as  in  chronic 
nephritis,  gout,  or  lithemia;  (/)  arteriosclerosis  and  other  conditions 
producing  increased  arterial  tension  or  resistance. 

Hypertrophy  of  the  right  ventricle  results  from  :  {a)  Mitral  insuffi- 
ciency or  stenosis,  and  remotely  from  aortic  lesions;  (Ji)  lesions  of  the 
pulmonary  valves,  not  of  frequent  occurrence ;  (/)  obstruction  or  partial 
obliteration  of  the  circulation  in  the  lungs,  as  in  emphysema  and  inter- 
stitial pneumonia;  (^)  pericardial  adhesions. 

Hypertrophy  of  the  Auricles.— '^vm.-^le  hypertrophy  of  the  auricles  per- 
haps never  occurs,  but  hypertrophy  with  dilatation  is  a  constant 
result  of  valvular  lesions  or  changes  in  the  circulation  which  increase 
the  intrapulmonary  tension.  In  the  left  auricle  it  is  due  to  mitral  in- 
competency or  stenosis;  in  the  right,  to  any  of  the  valvular  lesions 
that  retard  the  flow  of  blood  through  the  lungs,  or,  rarely,  to  tricuspid 
stenosis. 

Morbid  Anatomy.— The  heart  is  often  increased  to  double  its  normal 
weight.  The  greatest  hypertrophy  is  usually  found  in  the  left  ventricle. 
The  walls  of  the  affected  chambers  may  be  double  their  normal  thick- 
ness; those  of  the  ventricles  sometimes  attain  to  treble  thickness.  The 
heart  appears  wider  than  normal  and  the  apex  less  pointed.  The  muscle 
substance  is  firm  and  dense  in  simple  hypertrophy.  The  enlargement  is 
probably  due  to  hyperplasia  (numerical  hypertrophy). 

Symptoms.— Simple  hypertrophy  the  result  of  physical  exercise,  or 
when  it  is  compensatory,  does  not  usually  produce  symptoms  so  long 
as  the  heart's  action  is  not  disturbed  by  pathological  conditions  in 
other  organs,  as  by  indigestion  or  general  ill-health.  When,  however, 
the  rhythm  is  disturbed,  the  abnormal  force  of  the  heart's  action  be- 
comes apparent  in  the  production  of  precordial  uneasiness,  headache, 
flushing  of  the  face,  vertigo,  tinnitus,  and  visual  disturbances.  Pain 
is  unusual.  The  patient  experiences  unpleasant  sensations,  more  partic- 
ularly when  he  hes  on  the  left  side.  Arteriosclerosis  is  often  associated 
with  the  hypertrophy  in  cases  arising  from  obstruction  of  the  peripheral 
circulation  and  may  give  rise  to  symptoms.  With  disease  of  the  blood- 
vessels added  to  the  increased  force  of  the  heart's  action,  there  is  greater 


HYPERTROPHY  OF  THE  HEART  353 

danger  of  rupture  and  hemorrhage,  particularly  into  the  brain.  When 
compensation  fails,  a  different  train  of  symptoms  is  added. 

Physical  Signs. — Inspection. — In  some  cases,  especially  in  children,  the 
precordial  region  is  abnormally  prominent.  The  cardiac  impulse  is 
strong  and  diffused.  The  apex  beat  is  displaced  downward  and  out- 
ward, the  extreme  limit  being  the  eighth  intercostal  space  and  3  inches 
(7.5  cm.)  beyond  the  nipple.  Palpation  reveals  a  strong  heaving  im- 
pulse usually  with  slow  action.  A  second  impulse,  an  apparent  rebound, 
is  sometimes  observed. 

The  pulse  in  uncomplicated  hypertrophy  is  full  and  regular,  but  in- 
creased in  tension,  often  throbbing.  It  may  be  normal  or  increased 
in  rapidity,  but  rapidity  and  irregularity  are  generally  the  first  indi- 
cations of  failing  compensation. 

Percussion. — The  dullness  is  increased  in  all  directions,  so  that  it  may 
extend  from  the  second  intercostal  space  downward  on  the  left  sternal 
margin,  and  from  the  right  border  to  one  or  two  inches  beyond  the 
left  nipple.     The  apex  is  more  rounded  than  normal. 

Auscultation.— Tht  first  sound  of  the  heart  in  simple  hypertrophy  is 
dull  and  long;  it  may  be  reduplicated,  especially  in  the  hypertrophy 
following  chronic  nephritis.  In  young  subjects  it  sometimes  has  a  metal- 
lic quality.  The  second  sound  is  also  strong  and  may  be  reduplicated 
or  metallic  in  the  aortic  region.  The  physical  signs  accompanying  hyper- 
trophy due  to  valvular  disease  have  been  considered  in  connection  with 
the  different  forms  of  these  lesions,  and  need  not  be  repeated. 

Diagnosis. — Simple  hypertrophy  is  to  be  differentiated  chiefly  from 
nervous  palpitation  and  pericardial  effusion  or  other  conditions  which 
increase  the  area  of  dullness. 

Nervous  palpitation  is  seen  for  the  most  part  in  exophthalmic  goiter, 
the  tobacco  heart,  neurasthenia,  or  prolonged  overwork.  In  this  con- 
dition the  impulse  is  strong,  but  not  heaving,  and  the  action  is  more 
rapid  than  in  simple  hypertrophy.  The  area  of  dullness  is  not  so  much 
enlarged.  The  first  sound  is  sharp,  and  the  second  diminished  in  force, 
as  a  rule. 

In  pericardial  effusion  the  area  of  dullness  is  triangular,  with  the 
base  downward ;  the  heart-sounds  are  feeble  and  distant  and  the  action 
is  increased.  The  pulse  is  rapid  and  weak  and  th^  patient  is  acutely  ill. 
Aneurism,  mediastinal  tumor,  pyloric  adhesions  due  to  interstitial 
pneumonia  or  tuberculosis  may  produce  conditions  simulating  hyper- 
trophy, but  the  diagnosis  can  generally  be  made  from  the  normal  posi- 
tion of  the  apex,  normal  sounds  often  without  increased  area  of  dullness, 
and  the  regular,  normal  character  of  the  pulse,  except  as  it  may  be 
modified  by  the  other  conditions  present. 

Hypertrophy  with  dilatation  is  excluded,  but  not  always  with  certainty, 
by  the  greater  force  and  regularity  of  action,  and  to  some  extent  also 
by  the  absence  of  murmurs  and  the  more  forcible  and  distinct  second 
sound,  slow  full  pulse,  and  entire  absence  of  evidences  of  pulmonary 
engorgement.  '" 

Error  in  diagnosis  is  possible  when  emphysematous  expansion  of  the 
lungs  obscures  the  outline  of  the  enlarged  heart  and  renders  its  recog- 
nition more  difficult. 

Prognosis. — The    prognosis    is    good    while    the  action  of  the    heart 

23 


354  PRACTICE  OF  MEDICINE 

remains  normal,  or  when  it  is  sufficient  to  maintain  compensation. 
Hypertrophy  from  active  exercise  is  not  incompatible  with  many  years 
of  good  health.  The  prospects  in  a  given  case  depend  upon  the  cause 
of  the  condition  and  the  stage  that  it  has  reached.  Failure  must  come, 
however,  and  it  may  be  initiated  with  great  suddenness  by  some  inter- 
current disease,  great  fatigue,  or  mental  strain.  After  compensation 
has  failed,  the  history  of  the  case  is  one  of  dilatation  or  myocarditis, 
and  the  prognosis  is  correspondingly  less  favorable. 

Treatment. — During  the  stage  of  simple  hypertrophy  with  regular 
action  of  the  heart,  no  treatment  is  required  further  than  the  avoidance 
of  fatigue,  excesses,  and  all  other  influences  capable  of  disturbing  the 
condition.  After  compensation  has  failed,  the  treatment  is  that  of 
dilatation. 

DILATATION  OF  THE  HEART. 

Definition. — Increase  in  the  size  of  the  heart-chambers,  with  or  with- 
out increase  in  the  thickness  of  their  walls.  In  some  cases  the  walls 
become  abnormally  thin. 

Etiology. — The  two  great  causes  of  dilatation  are  weakness  of  the 
walls  and  increase  of  internal  pressure.  These  may  operate  separately 
or,  as  is  more  frequent,  together.  Dilatation  sometimes  develops  with- 
out previous  hypertrophy,  developing  suddenly,  as  a  rule,  or  it  may 
succeed  hypertrophy.  It  may  arise  from  internal  tension  which  the 
walls  are  unable  to  overcome,  or  from  degenerative  changes  in  the  muscle 
more  or  less  directly  due  to  the  hypertrophy.  Once  established,  the 
dilatation  increases  through  its  own  impairment  of  the  circulation. 
The  heart-cavities  are  constantly  overfilled,  and  increased  tension  is 
maintained.  The  nutrition  of  the  muscles  is  diminished,  and  the  degen- 
erative change  is  thus  promoted.  An  acute  dilatation  is  often  overcome 
for  a  time  by  the  compensatory  hypertrophy,  but,  after  the  compensation 
has  failed,  the  dilatation  increases  and  often  becomes  extreme.  The 
causes  which  have  been  enumerated  as  producing  hypertrophy,  as  the 
prolonged  exertion  in  athletic  training,  sometimes  lead  to  dilatation 
with  little  or  no  hypertrophy.  The  dilatation  may  be  acute  and  ter- 
minate fatally.  Dilatation  sometimes  follows  degeneration  of  the  heart 
muscles  as  a  result  *of  the  acute  infectious  diseases,  notably  typhoid 
fever,  erysipelas,  and  pneumonia.  It  is  then  attributed  to  the  anemic 
condition  or  to  the  action  of  toxins  circulating  in  the  blood.  There 
seems  to  be  an  intimate  relation  in  some  cases  between  cardiac  dilata- 
tion and  excessive  beer-drinking,  especially  among  the  workers  in  brew- 
eries. Dilatation  may  result  from  the  degenerative  changes  occurring 
in  endocarditis  and  pericarditis,  sometimes  also  from  the  adhesions 
which  result  from  the  latter  affection.  In  advanced  interstitial  myo- 
carditis, a  more  localized  dilatation  occurs  at  the  point  that  is  most 
markedly  sclerotic,  generally  at  the  apex  of  the  left  ventricle.  In  some 
cases  of  dilatation,  especially  in  those  of  sudden  development,  no  cause 
can  be  discovered,  and  the  condition  is  often  described  as  idiopathic. 

Morbid  Anatomy.— The  condition  of  the  different  heart-chambers  is 
variable.  The  dilatation  is  usually  associated  with  hypertrophy  of  the 
walls,  and  affects  two  or  more  chambers  at  the  same  time.  The  most 
exti'eme  dilatation  is  seen  in  aortic  insufficiency,   for  all  chambers  are 


DILATATION  OF  THE  HEART  355 

then  affected.  The  right  ventricle  is  subject  to  more  extreme  dilatation 
than  the  left,  and  the  left  auricle  than  the  right.  The  endocardium 
is  generally  opaque,  and  the  myocardium  is  found  in  various  stages 
of  degeneration,  for  the  most  part  fatty  or  parenchymatous.  Changes 
of  a  degenerative  nature  have  been  observed  also  in  the  ganglia.  Dilata- 
tion of  the  veins  at  the  point  where  they  enter  the  auricle  is  commonly 
present. 

Symptoms. — Dilatation  associated  with  compensatory  hypertrophy, 
may  for  a  long  time  be  unrecognizable  by  symptoms.  Developing  slowl}-, 
as  it  usually  does,  the  dilatation  may  be  for  a  time  concealed  by  the 
forcible  action  of  the  heart.  But  increasing  dilatation  means  increasing 
weakness,  and  the  time  finally  comes  when,  perhaps  as  a  result  of 
some  unusual  strain,  the  hypertrophied  walls  become  unable  to  properly 
empty  the  chambers  during  systole,  and  definite  symptoms  are  pro- 
duced. In  the  acute  dilatation,  which  is  sometimes  seen  in  connection 
with  the  acute  infectious  diseases,  the  symptoms  are  often  abrupt  and 
severe.  They  are  the  same  in  character,  however,  whether  they  are 
sudden  or  slow  in  development,  for  in  both  instances  they  are  the  mani- 
festations of  venous  engorgement  of  the  lungs  and  of  the  general  cir- 
culation. 

The  symptoms  on  the  part  of  the  pulmonary  circulation  are  the 
same  as  those  that  have  been  described  in  connection  with  valvular 
lesions,  notably  dyspnea.  Bronchitis  is  generally  present,  and  edema  of 
the  lungs  is  likely  to  develop  as  a  late  or  terminal  condition.  Hydro- 
thorax  may  ensue  in  one  or  both  sides. 

The  symptoms  of  general  venous  engorgement  appear  in  different 
parts  of  the  body.  They  include  engorgement  of  the  vessels  of  the  neck 
and  face,  and  in  severe  cases  headache,  dizziness,  tinnitus,  visual  dis- 
turbances, sometimes  delirium,  and  later  stupor  or  coma  from  edema 
of  the  brain.  The  stomach  and  intestines  respond  to  the  congestion 
in  various  disturbances  of  their  functions.  The  liver,  spleen,  and  kid- 
neys are  also  involved,  and  later  a  general  dropsy  develops,  beginning 
in  the  feet,  as  a  rule,  and  gradually  extending  upward  to  finally  involve 
the  serous  cavities  and  upper  extremities  and  most  noticeable  in  the 
dependent  portions  of  the  body,  as  in  the  loins,  when  the  patient  is 
confined  to  bed.  Pain  in  the  region  of  the  heart  is  sometimes  complained 
of,  and  it  may  radiate  to  the  left  shoulder  and  arm.  Attacks  of  angina 
are  observed  in  some  cases. 

Physical  Signs. — Inspection  and  palpation  show  an  increased  but 
diffuse  area  of  pulsation,  often  so  undulatory  and  feeble  that  the  loca- 
tion of  the  apex  cannot  be  definitely  determined.  The  direction  in  which 
the  greatest  increase  of  dullness  occurs  depends  upon  the  relative  dilata- 
tion of  the  right  and  left  sides  of  the  heart,  which  has  been  considered 
under  the  several  valvular  lesions.  A  murmur  may  not  be  heard  at 
ixny  time,  but,  as  a  rule,  if  there  has  not  been  a  valvular  defect  in  the 
beginning  as  a  causative  factor  in  the  production  of  the  dilatation,  a 
relative  insufficiency  of  the  mitral  or  tricuspid  valve  results  from  the 
dilatation,  and  a  bruit  is  then  heard. 

Interesting  changes  of  rhythm  sometimes  occur,  the  most  important 
of  which  are  the  galloping  rhythm  and  embryocardia.  In  the  former 
the  heart-beats  resemble  the  foot-falls  of  a  cantering  horse;  in  the  latter 


356  PRACTICE  OF  MEDICINE 

the  first  sound  is  so  similar  to  the  second  that  it  cannot  be  readily 
distinguished,  thus  resembhng  the  sounds  of  the  fetal  heart. 

The  radial  pulse  is  generally  weak  and  may  show  greater  irregularity 
than  is  perceptible  in  the  heart's  action,  several  beats  often  being  lost 
between  those  that  are  perceptible. 

/7/a^/70S/s.— Enlargement  of  the  heart  due  to  hypertrophy  is  distin- 
guishable by  the  strong  impulse,  distinct  apex  beat,  accentuated  second 
sound,  and  strong,  full,  regular  pulse,  without  evidences  of  venous  en- 
gorgement. 

Pericardial  effusion  is  distinguished  by  the  triangular  dullness  with 
the  greatest  diameter  below,  often  producing  an  area  of  dull  tympany 
in  the  left  infrascapular  region.  Evidences  of  compression  of  the  left 
lung  are  also  recognizable  in  some  cases. 

Prognosis.— Acute  dilatation  sometimes  proves  rapidly  fatal,  but  it 
is  generally  recovered  from.  The  dilatation  of  lost  compensation  is 
always  unfavorable,  but  life  can  be  greatly  prolonged  in  most  cases  by 
judicious  treatment. 

Treatment.— In  a.n  acute  dilatation, hfe  can  sometimes  be  saved  through 
venesection,  25  to  30  ounces  of  blood  being  promptly  abstracted,  as 
so  strongly  advocated  by  Osier.  The  subsequent  treatment,  and  that 
of  chronic  cases,  resolves  itself  into  the  administration  of  digitalis, 
with  perhaps  one  or  more  of  the  other  measures  advocated  under  the 
treatment  of  valvular  lesions  with  loss  of  compensation.  The  patient 
should  be  made  comfortable.  He  is  compelled  to  sit  up  in  bed.  By 
the  use  of  a  suitable  back-rest,  he  may  be  saved  from  great  suffering 
due  to  the  extreme  anasarca  that  is  so  common  in  those  compelled  to 
occupy  a  chair. 

DISEASES  OF  THE  MYOCARDIUM. 

MYOCARDITIS. 

Definition.— hxi  inflammatory  or  degenerative  disease  of  the  muscu- 
lar substance  of  the  heart.  It  may  be  either  acute  or  chronic,  and 
affects  in  one  group  of  cases  the  parenchyma,  the  fibers,  in  another 
group  the  interstitial  connective  tissue.  The  inflammation  is  some- 
times limited  to  a  small  area  and  is  then,  as  a  rule,  suppurative. 

Acute  Myocarditis.— £^/o/o57.— The  disease  may  occur  at  any  age, 
but  it  is  more  common  in  men.  The  principal  causes  are  :  («;)  An  infec- 
tious principle,  probably  a  toxemia,  resulting  from  the  acute  infectious 
diseases,  particularly  typhoid  fever  and  typhus;  Qb^  various  auto- 
intoxications ;  (0  endocarditis  or  pericarditis,  most  frequently  occurring 
in  the  course  of  acute  rheumatism  (rheumatic  myocarditis) ;  (<^)  embol- 
ism of  the  branches  of  the  coronary  arteries,  especially  in  pyemia  or 
ulcerative  endocarditis. 

lUorbid  Anatomy.— The  lesions  may  be  studied  under  three  heads 
corresponding  to  the  general  parenchymatous,  the  interstitial,  and  the 
circumscribed  forms  of  the  disease.  («)  In  the  parenchymatous  form 
the  muscle  fibers  are  found  in  a  state  of  granular  degeneration,  infil- 
trated with  granular  matter,  opaque  and  pale,  sometimes  showing  pro- 
hferation  of  the  nuclei.  The  transverse  striations  are  more  or  less  com- 
pletely lost.     (Zi)   In  the  interstitial  form  the  interfibrillary  connective 


DISEASES  OF  THE  MYOCARDIUM  357 

tissue  is  infiltrated  with  small  round  formative  cells  as  if  in  the  initial 
stage  of  hyperplasia.  (^)  The  circumscribed  form  is  generally  due  to 
the  lodgment  of  septic  emboli.  The  process  is  therefore  limited  to  one 
or  more,  generally  to  many,  small  areas  of  the  intermuscular  connective 
tissue,  and  it  is  generally  suppurative  in  character.  Rupture  of  the 
small  abscesses  thus  formed  sets  up  pyemic  processes  in  various  parts 
of  the  body.  In  some  cases,  however,  the  abscesses  become  encysted 
and  their  contents  undergo  caseous  or  calcareous  change.  Fatal  rupture 
of  the  heart  is  sometimes  induced.  A  nonseptic  form  of  circumscribed 
myocarditis  is  occasionally  met  with  in  which  limited  areas  undergo 
fatty  or  hyalin  degeneration.  The  heart  becomes  irregularly  dilated. 
Cardiac  aneurism  is  one  of  the  possible  results  of  this  form  of  myo- 
carditis. 

Symptoms. — The  symptoms  are  indefinite  and  are  not  distinctive  of 
the  lesions.  The  heart's  action  usually  becomes  feeble  and  irregular; 
there  may  be  palpitation  and  slight  distress,  with  more  or  less  pro- 
nounced dyspnea,  sometimes  cyanosis  and  cold  sweats.  The  pulse  is 
small,  soft,  irregular,  and  increasingly  weak  with  the  progress  of  the 
disease.  The  lungs  may  become  congested  and  produce  cough.  The 
urine  is  diminished  in  quantity.  Delirium  sometimes  develops.  The 
physical  signs  are  generally  those  of  dilatation,  a  possible  accompani- 
ment of  the  other  pathological  changes.  The  sounds  are  at  first  strong 
and  clear,  while  the  heart's  action  is  forcible,  but  they  become  more  and 
more  indistinct  as  the  degenerative  changes  become  more  pronounced. 
Murmurs  are  sometimes  heard  which  are  attributable  to  the  irregular 
contraction  of  the  muscle  bundles  in  different  parts  of  the  heart-wall. 
They  are  probably  due  also  in  some  instances  to  the  dilatation,  degen- 
eration of  the  papillary  muscles,  or  the  pressure  of  abscesses  situated 
near  the  valves. 

Prognosis. — The  diffuse  form  is  almost  invariably  fatal,  and  sudden 
death  after  slight  exertion  is  not  unusual.  The  circumscribed  form 
may  be  recovered  from,  but  a  guarded  prognosis  should  always  be  ex- 
pressed. 

Treatment. — The  treatment  is  that  of  acute  endocarditis  or  pericar- 
ditis, with  which  the  affection  is  often  associated.  Absolute  rest  is  im- 
perative. Heart  tonics  are  not  usually  indicated,  even  when  the  action 
is  irregular  and  feeble,  and  their  administration  is  often  dangerous. 
Small  doses  of  strychnin,  gr.  1-60  (o.ooi)  or  less,  may  be  used  with 
caution,  but  digitalis  would  better  be  omitted.  The  nutrition  should 
be  carefully  sustained. 

Chronic  Myocarditis.— /7ey7/?/V/o/7.— A  chronic  proliferative  inflamma- 
tion of  the  interstitial  connective  tissue  of  the  heart  muscle. 

Etiology. — The  disease  is  more  frequently  met  with  in  men  after 
middle  life.  The  most  frequent  cause  is  the  presence  of  toxic  matter 
in  the  blood.  This  may  be  inferred  from  the  fact  that  the  disease  is 
most  common  in  the  subjects  of  chronic  alcoholism,  syphilis,  rheumatism, 
gout,  diabetes,  malaria,  chronic  nephritis,  or  chronic  poisoning  with 
lead  or  tobacco.  It  sometimes  results  from  endocarditis  or  pericarditis 
and  it  has  been  attributed  to  traumatism  of  the  chest-wall.  In  many 
cases  it  is  associated  with  disease  of  the  coronary  arteries. 

Morbid  Anatomy. — The  typical  lesion  is  an  induration  of  the  muscle 


3  58  PRACTICE  OF  MEDICINE 

due  to  the  increase  of  connective  tissue.  This  may  be  general,  but  it 
is  more  frequently  limited  to  one  or  more  definite  areas,  and  commonly 
to  the  ventricular  septum,  the  region  of  the  apex,  and  the  papillary  mus- 
cles. The  indurated  tissue  can  be  recognized,  when  of  sufficient  size,  by 
its  firmness  and  gray  color. 

Narrowing  of  the  orifices,  particularly  those  of  the  aorta  and  pul- 
monary arteries,  is  sometimes  recognizable,  or  there  may  be  an  incompe- 
tency of  the  valves.  Compensatory  hypertrophy  is  often  present.  The 
intima  of  the  coronary  arteries  may  be  sclerotic  as  a  result  of  the  myo- 
carditis, or,  on  the  contrary,  as  a  previous  affection  bearing  an  etiologi- 
cal relation  to  the  myocarditis.  Fatty  degeneration  of  the  muscle  fibers 
is  common,  and  fragmentation  and  segmentation  are  generally  observed. 
In  the  former  condition  the  muscle  fibers  have  been  broken  transversely ; 
in  the  latter  they  have  separated  along  the  cement  line. 

Symptoms. — These  are  exceedingly  indefinite  and  rarely  so  numerous 
or  distinctive  as  to  permit  an  exact  diagnosis.  The  condition  is  often 
discovered  at  autopsy.  Disturbances  of  rhythm  are  more  or  less  com- 
mon. The  heart  becomes  irregular  in  its  action,  fast,  slow,  or  unsteady, 
and  feeble.  This  is  accompanied  with  dyspnea,  a  sense  of  weight  or 
oppression  in  the  precordial  region,  physical  and  mental  debility;  and 
later,  attacks  of  cardiac  asthma  supervene.  There  may  be  sudden 
severe  attacks  of  pain  (angina  pectoris),  more  particularly  when  the 
coronary  arteries  are  involved.  The  disease  may  exist  for  a  long  time 
without  producing  serious  impairment  of  health,  but  it  sometimes  ter- 
minates fatally  with  the  suddenness  of  apoplexy. 

Treatment.— The  treatment  is  principally  hygienic.  The  patient  should 
avoid  undue  exertion,  exposure,  and  excesses  of  all  kinds.  Residence  in 
a  mild  climate  during  the  winter  may  prolong  life.  In  other  respects 
the  treatment  should  be  that  of  dilatation  and  other  conditions  produc- 
ing feeble,  irregular  action  of  the  heart.  Strychnin  in  small  doses  is 
often  the  best  tonic.  The  attacks  of  angina  must  be  treated  with 
morphin  and  the  other  remedies  recommended  under  Angina  Pectoris. 

DISEASES  OF  THE  CORONARY  ARTERIES. 

The  diseases  of  the  coronary  arteries  are  of  importance  chiefly  on 
account  of  their  effects  upon  the  heart  muscle.  The  principal  accidents 
to  the  vessels  are:  («)  They  maybe  blocked  by  emboh;  ((^)  they  may 
be  the  seat  of  arteriosclerosis,  (^)  thrombosis,  or  (^/)  obliterative 
endarteritis.  Sudden  blocking  of  one  of  the  coronary  arteries  is  gener- 
ally followed  by  instant  death.  Incomplete  closure,  coming  on  slowly, 
as  in  arteriosclerosis  or  obliterative  endarteritis,  produces  degenerative 
changes  in  the  muscle,  together  with  various  clinical  manifestations. 
The  coronary  arteries,  being  end  arteries,  their  occlusion  produces  in- 
farction, which  is  generally  known  as  anemic  or  white  infarction,  and 
the  subsequent  necrosis  is  termed  anemic  necrosis. 

The  anemic  infarct  is  most  frequently  due  to  embolism  of  the  anterior' 
artery,  and  the  necrotic  areas  are  therefore  situated  in  the  left  ventricle 
and  septum.  The  area  has  not  always  the  wedge  shape  of  other  infarctions. 
It  is  usually  small,  slightly  elevated,  with  irregular   margins,  yellowish 
gray  or  reddish  gray  color,  and  a  white  center.     The  muscle  fibers  lose 


DISEASES  OF  THE  MYOCARDIUM  359 

their  striations  and  become  granular.  They  ma}^  preserve  their  firm- 
ness to  a  considerable  extent;  or  they  may  undergo  fragmentation  or 
a  more  complete  softening,  especially  in  the  center  of  the  necrotic  mass 
(myomalacia  cordis).  When  the  disease  does  not  prove  fatal  through 
rupture  of  the  heart  or  other  accident,  the  necrotic  tissue  is  replaced 
by  a  new  growth  of  fibrous  tissue,  the  process  constituting  a  chronic 
interstitial  myocarditis.  Aneurism  of  the  heart  is  a  frequent  sequel. 
When  the  emboli  are  septic,  the  process  established  is  one  of  suppurative 
myocarditis. 

Symptoms. — The  symptoms  are  often  exceedingly  obscure.  Complete 
closure  of  one  of  the  coronary  arteries  may  end  life  instantly.  When 
both  coronary  arteries  are  the  seat  of  arteriosclerosis,  sudden  death 
may  follow  thrombosis  with  only  partial  closure  of  either.  Sometimes 
the  sudden  fatal  termination  is  due  to  rupture  of  the  heart-wall  at  the 
site  of  an  anemic  necrosis.  In  cases  which  are  not  immediately  fatal 
the  heart's  action  becomes  feeble  and  disturbed  in  rhythm,  the  pulmonary 
engorgement  producing  cough  and  dyspnea.  Attacks  of  angina  pectoris 
occur,  and  death  often  takes  place  during  one  of  them,  sometimes  even 
in  the  first  attack.  In  other  cases  the  patient  suffers  repeated  seizures 
during  a  number  of  years.  Wlien  the  obstruction  of  the  coronary  cir- 
culation is  but  partial,  the  heart  muscle  undergoes  a  slower  degenera- 
tion and  the  symptoms  are  of  moderate  severity. 

FATTY   HEART. 

The  heart  becomes  fatty  either  as  a  result  of  over-accumulation  of 
adipose  tissue   (infiltration)   or  as  a  result  of  fatty  degeneration. 

1.  Fatty  Overgrowth.— The  former  condition  is  most  frequent  after 
the  age  of  forty  and  in  men.  In  many  cases  the  fat  in  simpl}'^  massed 
beneath  the  pericardium,  especially  around  and  between  the  auricles, 
and  along  the  auriculoventricular  groove,  and  the  condition  is  a  part 
of  a  general  obesity.  In  extreme  cases  the  heart  becomes  completely 
covered  with  a  thick  layer  of  fat,  which  impedes  its  action,  and  there 
is  often  added  to  this  an  infiltration  between  the  muscle  bundles  to  a 
variable  depth,  occasionally  extending  to  the  entire  thickness  of  the  wall. 
Fatty  degeneration  of  the  muscle  ensues,  and  in  some  instances  the 
adipose  tissue  has  been  found  to  have  entirely  taken  the  place  of  the 
muscle  fibers.  Dilatation  follows  the  weakening  of  the  walls.  The  heart 
is  large,  yellow,  and  flabby.  The  change  is  generally  more  common  and 
more  extensive  in  the  right  ventricle  than  elsewhere. 

2.  Fatty  Degeneration. — This  is  a  common  affection  and  a  prompt 
result  of  many  conditions  which  cause  an  impairment  of  nutrition.  In 
this  relation,  it  is  probably  more  frequent  than  we  are  aware.  A  moder- 
ate degree  of  fatty  degeneration  may  occur  at  any  time  of  life :  (a)  In 
connection  with  the  infectious  diseases,  especially  those  of  septic  charac- 
ter, or  in  the  prolonged  febrile  affections,  as  tuberculosis  and  in  cancer. 
In  a  more  extreme  form  it  is  met  with  as  a  result  (/;)  of  the  primary 
anemia,  (r)  in  advanced  age,  (^^)  as  a  result  of  poisoning  with  phos- 
phorus, arsenic,  and  other  drugs,  or  (^)  following  abnormal  conditions 
in  the  heart,  as  chronic  pericarditis,  hypertrophy,  or  partial  obstruction 
of  the  coronary  arteries  from  sclerosis,  thrombosis,  or  embolism.    The 


36o  PRACTICE  OF  MEDICINE 

degeneration  is  often  associated  with  fatty  overgrowth  and  not  infre- 
quently also  with  fatty  degeneration  of  other  viscera,  especially  that  of 
the  diaphragm.  The  degeneration  may  involve  all  the  walls  of  the 
heart,  or  it  may  be  limited  to  those  of  one  chamber,  particularly  of  the 
left  ventricle,  often  including  the  papillary  muscles.  The  heart  is  greatly 
enlarged,  yellow,  flabby,  in  many  cases  resembling  the  condition  in  fatty 
infiltration;  but  in  other  cases  neither  the  size,  the  color,  nor  the  con- 
sistence is  much  changed,  and  the  degeneration  can  be  determined  only 
upon  microscopic  examination.     (See  Fatty  Degeneration,  p.  22). 

Symptoms. — The  history  of  a  case  of  fatty  degeneration  is  exceedingly 
variable.  An  extreme  grade  of  either  fatty  overgrowth  or  degeneration 
may  exist  for  an  indefinite  time  without  giving  rise  to  definite  disturb- 
ances. The  heart's  action  continues  full,  regular,  and  strong.  Much 
depends  upon  the  condition  of  the  chambers.  So  long  as  there  is  no 
dilatation  the  heart  may  functionate  normally.  With  dilatation  the 
symptoms  must  be  regarded  as  due  rather  to  this  condition  than  to  the 
degenerative  changes  in  the  walls.  There  is  then  more  or  less  pro- 
nounced dyspnea  upon  exertion,  and  possibly  slight  faintness  or  com- 
plete syncope,  and  attacks  of  angina  may  occur  during  the  night. 
Edema  often  develops  in  the  lower  extremities.  Sometimes  the  pulse 
becomes  extremely  slow,  not  more  than  40  or  even  30  beats  in  the 
minute,  and  along  with  these  symptoms  the  patient  has  attacks  of 
cardiac  asthma.  These  sometimes  accompany  or  alternate  with  attacks 
of  angina  pectoris.  A  peculiar  type  of  breathing  known  as  the  Cheyne- 
Stokes  is  sometimes  observed  in  extreme  cases,  but  it  is  more  common 
in  arteriosclerosis  and  uremia.  The  breathing  is  irregular.  About  once 
a  minute  the  respiratory  movement  ceases  for  15  seconds  or  more; 
then  it  is  slowly  re-established,  and  each  breath  becomes  stronger  until 
a  full,  sometimes  snoring  respiration  is  taken  and  the  movements 
stop,  or  they  may  grow  gradually  more  feeble  and  almost  imperceptibly 
cease. 

The  physical  signs  are  those  of  dilatation.  The  area  of  dullness  is 
increased,  however,  in  cases  of  overgrowth  before  actual  dilatation  has 
occurred.  The  heart-sounds  are  feeble,  but  this  is  often  due,  in  part 
at  least,  to  the  thickness  of  the  chest-wall.  Psychical  symptoms  are 
sometimes  a  distressing  feature.  Various  disturbances  of  the  mind, 
even  maniacal  seizures,  may  come  on  and  persist  for  weeks  or  months. 
More  or  less  complete  apoplectic  attacks  may  occur.  The  fatty  arcus 
senilis,  a  white  line  in  the  cornea,  is  not  of  the  diagnostic  significance 
it  was  once  supposed  to  be. 

The  diagnosis  between  the  different  forms  of  myocarditis  is  not  usu- 
ally possible.  A  fatty  heart  is  to  be  inferred  in  the  presence  of  great 
obesity  or  when  the  history  of  the  case  otherwise  points  to  it  as  a 
probable  condition.  The  heart  muscles  are  usually  fatty  also  in  a  con- 
dition of  dilatation  following  hypertrophy,  hence  it  may  be  inferred  to 
exist  in  nearly  all  cases  of  long-standing  valvular  disease. 

The  prognosis  is  always  grave.  Sudden  death  is  likely  to  occur  at 
any  time,  in  syncope,  as  a  result  of  c5verdistentioh  or  rupture  of  the 
heart.  Temporary  improvement  sometimes  occurs  in  cases  which  have 
not  advanced  to  extensive  dilatation,  but  relapse  occurs  later  in  all 
cases.    Complete  recovery  possibly  occurs  in  cases  of  slight  fatty  change 


DISEASES  OF  THE  MYOCARDIUM  361 

in  young  subjects  after  prolonged  febrile  disease,  but  it  is  never  possible 
in  the  aged  or  in  advanced  cases. 

Treatment. — When  an  opportunity  is  afforded  for  treatment,  it  should 
generally  be  directed  against  the  failing  compensation.  When  the  ac- 
tion is  irregular,  rapid,  or  weak,  and  when  dyspnea  or  edema  is  to 
be  overcome,  digitalis  may  be  employed  in  carefully  regulated  doses. 
When,  on  the  other  hand,  the  heart's  action  is  slow  and  feeble,  stimulants 
are  called  for,  and  digitalis  should  not  be  given.  Ammonium  carbonate 
or  the  aromatic  spirit,  and  strychnin  in  small  doses  (gr.  1-60;  o.ooi, 
or  less),  should  be  given,  but  no  especial  effort  should  be  made  to  in- 
crease the  force  of  the  heart's  action. 

Great  benefit  is  sometimes  obtained  from  the  Oertel  or  Schott  method 
of  treatment,  particularly  in  cases  of  general  obesity  induced  by  over- 
eating and  -drinking.  The  essential  features  of  the  Oertel  method  are : 
the  limitation  of  fluids  and  fats,  and  systematic  exercise,  especially 
mountain-climbing,  each  day  showing  an  increase  over  the  previous  day. 
The  Schott,  or  Nauheim,  method  consists  of  warm,  carbonated  salt-water 
baths  and  regular,  graduated,  resisted  exercise.  The  patient  makes 
voluntary  movements  of  the  muscles  of  the  arms,  thorax,  and  abdomen, 
while  the  operator  resists  them.  The  exercise  is  made  more  and  more 
vigorous  until  a  decided  improvement  of  the  respiratory  capacity  and 
power  in  particular  becomes  apparent.  Muscles  which  have  been  per- 
mitted to  atrophy  from  disuse  are  carefully  brought  out  and  strength- 
ened in  the  exercises.  The  treatment  can  be  carried  out  at  home  with 
little  difficulty  and  often  with  excellent  results. 

Other  Degenerations  of  the  Heart.— Most  of  the  other  degenerations 
of  the  heart  are  of  greater  pathological  interest  than  clinical. 

Parenchymatous  degeneration  is  often  associated  with  fatty  degen- 
eration, or  it  may  precede  it.  In  this  relation,  or  independently,  it 
occurs  as  a  result  of  endocarditis,  pericarditis,  acute  or  chronic  infection, 
or  intoxication.    The  histological  appearances  are  described  on  page  21. 

In  brown  atrophy,  the  heart  becomes  reduced  in  size  and  is  firmer 
than  normal,  and  it  has  a  dark,  reddish-brov/n  color.  The  muscle 
fibers  become  pigmented,  especially  about  the  nuclei,  and  more  or  less 
completely  lose  their  striations.  It  is  usually  a  condition  of  old  age, 
but  may  occur  as  a  result  of  chronic  valvular  disease.  Amyloid,  hyalin, 
and  calcareous  degenerations  are  occasionally  met  with  in  the  heart 
muscle.    They  are  described  under  the  head  of  Degenerations,  page  2^. 

Aneurism  of  the  Heart. — i.  Aneurism  of  a  valve  is  an  occasional 
result  of  endocarditis.  It  follows  an  ulceration  or  erosion  that  has  ex- 
tended deeply  enough  to  permit  dilatation  of  the  valve-segment  with- 
out perforation.  They  are  found  projecting  from  the  ventricular  surface 
of  one  of  the  cusps  of  the  valve,  most  frequently  on  the  aortic,  seldom 
on  the  mitral  valve.  Rupture  of  the  little  aneurismal  sac  sometimes 
occurs. 

2.  A  saccular  bulging  of  the  ventricular  wall  sometimes  occurs  at  a 
point  where  the  muscle  has  become  weakened  by  myocarditis,  anemic 
necrosis,  or  sclerosis.  It  has  been  met  with  also  as  a  result  of  the 
gummatous  syphilid  of  the  heart-wall,  the  cicatrization  of  a  stab- 
wound,  and  sometimes  apparently  as  a  result  of  pericardial  adhesions. 
They  are  almost  invariably  situated  in  the  wall  of  the  left  ventricle 


362  PRACTICE  OF  MEDICINE 

near  the  apex,  and  they  vary  in  size  from  that  of  a  walnut  to  that  of 
the  heart  itself.  The  exterior  is  usually  smooth  and  firm,  like  the  heart- 
wall,  but  the  interior  is  lined  with  superimposed  layers  of  fibrin.  The 
aneurismal  sac  sometimes  communicates  with  the  ventricle  by  a  very 
small  orifice. 

The  s/mpfoms  are  vague,  VVlien  the  aneurism  becomes  large  it  some- 
times causes  bulging  or  complete  perforation  of  the  anterior  chesL-wall 
in  the  region  of  the  apex.  The  physical  signs  are  so  indefinite  that 
the  diagnosis  is  seldom  made  during  life. 

Rupture  of  the  Heart. — This  rare  accident  occurs  only  in  a  heart 
that  has  previously  been  weakened  by  disease.  In  a  majority  of  cases 
it  has  been  found  due  to  fatty  degeneration,  but  it  sometimes  follows 
endocardial  ulceration,  anemic  necrosis,  aneurism  or  gumma  of  the  ven- 
tricular wall.  Most  patients  have  passed  the  sixtieth  }'ear  of  age.  The 
rupture  is  generally  found  in  the  anterior  wall  of  the  left  ventricle,  per- 
mitting the  escape  of  the  blood  into  the  pericardial  sac;  but  it  may 
perforate  any  of  the  heart-walls;  and  when  pericardial  adhesions  are 
present  the  blood  may  be  poured  into  the  mediastinal  or  pleural  cav- 
ities. In  some  cases  a  rupture  of  the  ventricular  septum  has  been  dis- 
covered. The  rupture  generally  occurs  during  some  exertion,  and  the 
result  is  almost  instantly  fatal.  In  a  few  instances  life  has  been  pro- 
longed for  a  few  hours.  When  instant  death  does  not  occur,  the  patient 
is  generally  prostrated,  suffers  intense  dyspnea,  with  sighing  respiration 
and  sense  of  suffocation,  sharp  pain  or  great  oppression  in  the  precordial 
region.  The  skin  becomes  moist  and  cold,  the  pulse  feeble  and  flutter- 
ing. Vomiting  may  occur.  The  expression  becomes  anxious  and  there 
is  often  a  distressing  sense  of  impending  death. 

New  Growths  and  Parasites  of  the  Heart.— Malignant  growths  are 
extremely  rare  in  the  heart,  but  secondary  growths  are  sometimes  met 
with  in  carcinoma,  epithelioma,  or  sarcoma  of  the  mediastinum  or  lung. 
The  melanotic  sarcoma  produces  numerous  small  nodules  through  me- 
tastasis. Nonmalignant  tumors  are  even  more  rare,  but  fibromata, 
myomata,  and  lymphomata  have  been  found.  Cysts  occasionally  form 
in  the  heart  muscle  in  extreme  fatty  degeneration  or  as  a  result  of 
hemorrhage  or  the  breaking  down  of  a  gumma.  Pyemic  abscesses  have 
been  referred  to  under  Circumscribed  Myocarditis. 

The  parasites  that  have  been  found  in  the  heart  are  the  trichina 
spiralis,  the  cysticercus  cellulosse,  and  the  echinococcus  cyst.  They 
have  not  been  recognized  during  life. 

Wounds  and  Foreign  Bodies. — The  more  serious  wounds  of  the  heart, 
due  to  gunshot,  stabs,  and  crushing,  are  of  greater  interest  to  the  sur- 
geon or  to  the  pathologist  than  to  the  physician.  The  heart  is  often 
injured  without  immediately  serious  result,  especially  by  foreign  bodies 
passing  through  the  wall  of  the  esophagus.  Penetrating  wounds  arc 
by  no  means  always  fatal.  Pricking  the  heart  has  been  suggested  as  a 
final  means  of  stimulating  it  to  action  in  cases  of  asphyxia  from  drown- 
ing, chloroform  or  illuminating-gas  poisoning.  The  symptoms  are  those 
of  gradual  rupture  of  the  heart,  with  slow  hemorrhage.  The  severity 
of  the  symptoms  is  not  always  proportionate  to  that  of  the  injury,  how- 
ever, for  profound  s3'ncope  may  follow  a  trivial  injury  which  is  soon  re- 
covered from,  and  a  fatal  wound  mav  at  first  occasion  little  disturbance. 


NEUROSES  OF  THE  HEART  363 

Foreign  bodies  entering  the  heart  from  the  esophagus  can  rarely  be 
recognized  during  hfe.  The  effect  is  often  Hmited  to  the  production  of 
a  pericarditis,  with  serous  or  purulent  effusion. 

Treatment.  —The  case  should  be  promptly  placed  in  the  hands  of  a  sur- 
geon. In  the  mean  time  the  patient  may  be  given  complete  rest,  with 
opium  if  necessary,  and  an  ice-bag  to  the  precordium.  Stimulants  must 
not  be  administered,  but  some  writers  favor  the  giving  of  aconite  to 
reduce  the  force  of  the  heart  and,  with  it,  the  blood  pressure. 

NEUROSES  OF  THE  HEART. 

Palpitation. — Definition. — Irregularity  in  the  frequency  or  force  of  the 
heart's  action,  which  is  perceptible  to  the  patient. 

Etiology. — Irregularity  of  action  characterizes  a  great  many  con- 
ditions of  the  heart,  especially  valvular  lesions  in  the  stage  of  lost 
compensation,  but  in  this  condition  the  patient  is  not,  as  a  rule,  con- 
scious of  the  palpitation,  and,  since  the  phenomenon  depends  upon  ana- 
tomical lesions,  it  is  not  strictly  a  neurosis.  There  are  cases,  too,  in 
which  severe  palpitation  is  complained  of  by  the  patient  when  the  heart's 
action  is  perfectly  normal.  Like  all  neuroses,  palpitation  is  generally 
observed  («:)  in  nervous,  hysterical,  or  neurasthenic  persons,  especially 
women  who  are  naturally  excitable  or  have  been  rendered  so  by  fright, 
work,  worry,  injury,  or  disease.  (<5)  It  is  often  associated  with  other 
neuroses,  especially  those  of  the  stomach,  and  it  is  not  uncommonly 
produced  by  the  upward  pressure  of  a  distended  or  dilated  stomach. 
(^)  Excessive  indulgence  in  alcohol,  tobacco,  coffee,  or  tea  is  regarded 
as  an  exceedingly  frequent  cause.  (1^)  Sexual  excesses  and  ovarian  or 
uterine  disease,  particularly  at  puberty  or  the  menopause,  often  incite 
it,  and  it  is  sometimes  complained  of  at  the  menstrual  periods.  Qe~)  It 
is  a  prominent  symptom  of  exophthalmic  goiter. 

The  irritable  heart  of  young  soldiers  described  by  Da  Costa  was  at- 
tributed to  mental  excitement,  excessive  muscular  exertion,  and  the 
prevalent  diarrhea. 

Symptoms. — In  addition  to  the  sensation  of  fluttering  felt  at  the 
heart,  the  patient  usually  experiences  a  peculiar  feeling  of  fullness  as 
though  the  heart  were  being  distended,  or  a  contrary  sense  of  vacancy 
and  slight  faintness.  The  action  of  the  heart  may  be  so  violent  as  to 
become  visible,  and  the  arteries  may  throb.  The  pulse  becomes  for  the 
time  extremely  rapid  and  the  patient  may  gasp  for  breath.  There  is 
sometimes  distinct  flushing  of  the  face,  sometimes  pallor.  Gaseous 
eructations  and  other  nervous  or  hysterical  manifestations  commonly 
accompany  the  attack.  The  physical  signs  are  not  definite.  The  sounds 
may  all  be  normal  in  character,  but  are,  as  a  rule,  accentuated  and 
metalHc  in  quality.  An  anemic  bruit  or  a  murmur  of  relative  insufiicicncy 
is  often  heard  at  the  base,  less  frequently  at  the  apex.  The  attack  is 
usually  of  short  duration,  subsiding  after  a  few  minutes  or  at  most 
after  a  few  hours,  to  recur  upon  any  trivial  provocation,  especially  after 
excitement  or  exertion. 

The  prognosis  is  generally  good  with  reference  to  life,  but  the  af- 
fection often  proves  resistant  to  treatment,  and  hypertrophy  often  re- 
mains. 


364  PRACTICE  OF  MEDICINE 

Treatment. — The  most  important  therapeutic  element  is  the  removal 
of  the  cause.  If  it  be  an  excessive  indulgence  in  alcohol,  tobacco,  or 
other  stimulant,  it  must  be  overcome;  if  a  disorder  of  digestion,  it 
should  receive  appropriate  treatment.  In  hysterical  cases  the  treatment 
is  largely  moral.  Care  should  be  exercised  not  to  impress  the  patient 
too  strongly  with  the  gravity  of  his  illness,  nor  yet  to  treat  it  too 
lightly.  All  excesses  should  be  avoided,  regular  exercise  should  be  taken ; 
the  mind  should  be  kept  free  from  worry.  It  is  generally  better  to  aban- 
don entirely  the  use  of  alcohol,  tobacco,  and  coffee.  Tonics  may  be 
required  in  some  cases,  especially  iron,  arsenic,  and  strychnin,  when 
anemia  is  present,  but,  as  a  rule,  the  administration  of  drugs  should 
be  abstained  from  as  far  as  possible.  All  forms  of  hot  baths  should 
be  avoided,  but  a  tepid  bath  may  be  taken  mornings  or  evenings  and 
followed  with  rubbing. 

ARRHYTHMIA. 
Loss  OF  Rhythm. 

This  is  observed  in  two  different  degrees.  In  the  lesser  only  the 
volume  and  force  of  the  pulsations  are  altered,  a  series  of  full,  strong, 
pulse-waves  alternating  with  a  series  of  weaker  pulsations.  In  the  more 
pronounced  arrhythmia,  the  irregularity  becomes  so  great  that  one  or 
more  waves  are  lost  before  reaching  the  radial  artery  at  the  wrist. 
This  may  occur  at  regular  or  at  irregular  intervals.  One  beat  may  be 
lost  after  every  series  of  three  or  four,  or  there  may  be  no  regularity 
in  the  omissions. 

Several  forms  of  irregularity  are  generally  selected  for  description, 
their  frequency  rendering  them  more  or  less  typical.  Among  these  are  : 
(«)  Intermittency,  in  which  every  third,  fourth,  fifth,  or  perhaps  every 
tenth  beat  is  omitted.  It  is  not  usually  a  condition  of  serious  import; 
(/?)  the  bigeminal  or  trigeminal  pulsation,  two  or  three  systoles  occur- 
ring in  quick  succession,  to  be  followed  by  an  increasing  interval.  An 
apparent  bigemism  is  often  produced  when  the  impulse  of  the  second 
systole  is  lost  before  it  reaches  the  radial  artery,  although  a  faint 
systole  may  be  heard  upon  auscultation.  This  condition  is  sometimes 
a  result  of  the  administration  of  digitalis.  The  purely  nervous  inter- 
mission is  to  be  distinguished  from  the  irregularity  due  to  valve  lesions, 
which  is  of  more  serious  import.  As  a  neurosis,  it  is  the  "  nervous  trick" 
referred  to  by  Fothergill,  but  v/hen  due  to  organic  disease  it  signifies 
failing  compensation. 

((t)  T\\&  paradoxical  pulse  indicates  weakness,  fibrous  adhesions  about 
the  root  of  the  aorta  or  a  chronic  pericarditis.  The  pulse  becomes  feeble 
and  usually  more  rapid  during  inspiration.  It  is  not  necessarily  ot 
unfavorable  prognosis,  and  in  some  cases  it  is  probably  not  strictly 
pathological,  depending  only  upon  respiration. 

(^)  Delirium  cordis  is  the  term  applied  to  extreme  irregularity  of  ac- 
tion and  force  seen  when  complete  loss  of  compensation  occurs  in  valv- 
ular disease  or  in  extreme  cases  of  exophthalmic  goiter. 

(/)  The  gallop,  or  cantering  rhytlwi,  is  a  form  of  rapidity  in  which  the 
heart-sounds  resemble  the  foot-falls  of  a  horse  in  a  cantering  gait.  The 
irregularity  of  action  can  sometimes  be  recognized  on  inspection  and 
palpation  as  well  as  on  auscultation.    A  third  sound   is  generally  to 


NEUROSES  OF  THE  HEART  365 

be  recognized  owing  to  a  reduplication  of  one  of  the  normal  sounds, 
the  second,  as  a  rule.  The  condition  develops  in  hypertrophy  due  to 
arteriosclerosis,  chronic  interstitial  nephritis,  or  profound  anemia,  and 
sometimes  in  the  myocarditis  of  the  acute  infectious  diseases. 

(_/)  Embryocardia,  or  a  fetal-heart  rhythm,  is  acquired  through  a 
shortening  of  the  long  pause,  the  first  and  second  sounds  at  the  same 
time  becoming  more  alike.  The  sounds  are  to  this  extent  more  like  those 
of  the  fetal  heart.  The  condition  develops  in  some  cases  of  dilatation 
and  sometimes  in  connection  with  the  infectious  fevers. 

Eiiology. — The  cause  of  arrhythmia  is  reflex;  the  impulse  may  arise: 
(rt')  In  the  central  nervous  system  after  hemorrhage,  trauma,  or  psychical 
disturbance;  (/')  it  maybe  peripheral,  when  it  arises  from  disorders  of 
the  stomach,  liver,  lungs,  or  kidneys,  or  from  disturbance  of  the  blood 
pressure  in  arteriosclerosis  and  other  obstruction,  or  from  profuse  hemor- 
rhage, (<:)  or  from  toxic  irritation,  as  that  of  alcohol,  coftee,  or  tobacco. 
To  these  causes  are  generally  added  the  influences  of  organic  diseases 
within  the  heart  itself,  including  degenerations,  dilatation,  and  changes 
in  the  ganglia.  Some  writers  refer  to  a  physiological  arrhythmia  em- 
bracing cases  of  irregularity  observed  in  children  during  sleep,  sometimes 
also  in  adults,  and  more  commonly  in  very  old  persons. 

Treatment. — The  principal  therapeutic  indication  is  the  cure  of  the 
imderlying  nervous  condition.  Drugs  should  seldom  be  administered 
for  the  immediate  condition. 

Tachycardia  (Rapid  Heart,  Heart-Hurry).— A  rapid  action  of  the 
heart,  even  exceeding  100  beats  in  the  minute,  is  sometimes  normal  to 
the  individual.  When  a  nervous  condition,  the  rapid  action  may  be 
constant,  or  it  may  occur  in  paroxysms  of  variable  duration. 

Etiology. — The  causes  are  for  the  most  part  the  same  as  those  of 
palpitation,  but,  unlike  the  latter  condition,  the  patient  is  often  unaware 
of  the  rapid  action.  The  direct  cause  is  probably  either  a  stimulation 
of  the  sympathetic  nerves  of  the  heart  or  a  suspension  of  pneumogastric 
control.  The  condition  often  follows  some  great  nervous  excitement,  as 
in  mania,  fright,  fear,  or  violent  exercise,  the  rapid  action  suddenly 
produced  persisting  for  many  days.  In  women  the  irritation  is  often 
regarded  as  reflex  from  the  uterus  or  ovaries,  and  it  is  often  encountered 
at  the  menopause.  Toxic  cases  are  recognized  as  resulting  from  the 
action  of  tobacco,  belladonna,  digitalis,  alcohol,  and  other  drugs.  Cases 
of  tachycardia  occur  also  as  a  result  of  anatomical  lesions,  especially 
in  connection  with  an  inflammation,  blood-clot,  or  tumor  in  the  medulla 
or  causing  pressure  on  the  pneumogastric  nerve,  as  well  as  in  some 
cases  of  myocarditis  or  sudden  dilatation.  Martins  regards  the  parox- 
ysmal form  as  due  to  sudden,  periodical  dilatation.  The  pulse-rate 
during  the  paroxysms  varies  from  100  to  more  than  200  in  the  minute. 
Each  attack  varies  from  a  few  minutes  to  several  hours,  and  they  often 
recur  after  intervals  of  only  a  few  days.  The  patient  may  be  conscious 
of  the  increased  rapidity  of  the  heart,  or  he  may  experience  only  a  vague 
feeling  of  uneasiness  in  the  cardiac  region.  Dyspnea  is  not  usually 
present,  but  the  patient  may  be  compelled  to  sit  down  or  to  assume  a 
recumbent  posture.  The  attacks  are  rarely  fatal  except  in  persons  of 
advanced  age;  they  often  recur  at  variable  intervals  for  many  years 
without  serious  consequences. 


366  PR.\CTICE  OF  MEDICINE 

Treafmenf.— The  patient  should  immediately  lie  down,  and,  if  the 
rapid  action  continue,  an  ice-bag  should  be  placed  over  the  h^art. 
A  physician  referred  to  by  H.  C.  Wood  obtained  immediate  relief  during 
many  years  from  drinking  ice-water  or  hot  coffee.  In  severe  attacks, 
morphin  should  be  administered  hypodermically.  Strophanthus,  aconite, 
and  other  heart  remedies  have  proved  of  benefit.  Complete  recovery 
is  extremely  rare,  however,  and  the  exciting  causes,  particularly  nervous 
excitement,  should  be  carefully  guarded  against. 

Bradycardia  (Brachycardia,  Slow  Heart).— Slow  action  of  the  heart 
is  sometimes  met  with  as  a  normal  condition;  it  is  occasionally  a 
family  peculiarity.  It  is  probably  much  less  frequent  as  a  pure  neu- 
rosis than  in  other  relations.  The  former  cases  are  generally  asso- 
ciated with  other  neuroses,  as  in  neurasthenic,  hysterical,  melan- 
cholic, maniacal,  paretic,  or  epileptic  subjects,  or  in  persons  of  extreme 
age.  Attacks  sometimes  follow  intense  suffering  or  the  emotions  of 
fright  or  grief 

( 1 )  A  physiological  bradycardia  is  recognized  as  a  result  of  exhaustion, 
inanition,  or  as  a  feature  of  the  puerperal  state. 

(2)  Pathological  bradycai-dia  is  common  :  (ji)  During  convalescence 
from  the  acute  infections,  especially  typhoid  fever,  pneumonia,  diph- 
theria, rheumatism,  and  meningitis;  (Ji)  in  chronic  diseases,  as  dyspepsia, 
ulcer,  cancer,  or  dilatation  of  the  stomach,  pulmonary  emphysema,  and 
diseases  of  the  liver;  (<r)  in  intoxications  by  lead,  alcohol,  coffee,  tea, 
digitalis,  aconite,  or  the  autointoxication  of  diabetes,  chronic  nephritis, 
anemia,  and  diseases  attended  with  jaundice;  (a^)  sometimes  in  diseases 
affecting  the  heart,  as  the  degenerations,  arteriosclerosis,  myocarditis, 
affections  of  the  coronary  arteries,  and  very  rarely  in  connection  with 
valvular  lesions.  {/)  It  is  occasionally  met  with  in  sunstroke  and 
in  diseases  of  the  skin  or  of  the  sexual  organs.  A  peculiar  form  of 
the  affection  is  that  described  by  Adams  and  Stokes,  in  which  the 
pulse  is  constantly  slow  and  the  patient  suffers  occasional  attacks  of 
syncope. 

Diagnosis.— Tht  condition  is  readily  recognized,  but  it  should  not  be 
diagnosticated  from  the  pulse  alone.  The  heart  should  be  examined 
by  auscultation,  for  in  some  instances  the  radial  pulse  indicates  a  slow- 
ness that  is  not  real,  but  due  to  a  failure  of  the  impulse  to  reach  the 
radial  arteries. 

Treatment  is  of  little  avail  unless  the  underlying  condition  can  be 
discovered  and  removed.  Tonic  doses  of  strychnin  are  beneficial  in  some 
cases. 

ANGINA  PECTORIS. 
Neuralgia  of  the  Heart,  Breast  Pang,  Stenocardia. 

Definition.— A  paroxysm  of  intense  precordial  pain  usually  extending 
into  the  neck  and  arms  and  attended  in  severe  cases  with  a  sense  of 
imminent  death.  It  is  a  symptom  of  several  pathological  conditions 
of  the  heart  and  blood-vessels,  especially  sclerosis  of  the  aorta  near  its 
origin  or  of  changes  in  the  coronary  arteries ;  it  is  probably  never  an 
independent  disease. 

Etiology. — This  affection  occurs  only  in  adults,   and  much  more  fre- 


NEUROSES  OF  THE  HEART  367 

quently  in  women  than  in  men.  It  sometimes  follows  the  Une  of  heredity. 
In  a  vast  majority  of  cases  arteriosclerosis  of  the  coronary  arteries 
or  of  the  aorta  is  the  direct  cause;  other  cases  are  associated  with 
myocarditis,  adherent  pericardium,  or  aortic  incompetency,  and  very  ex- 
ceptionally with  a  mitral  lesion.  Diabetes,  gout,  and  syphilis  are  com- 
monly observed  in  the  antecedent  history  of  the  patient,  and  in  recent 
years  influenza  has  appeared  to  bear  a  causal  relation  to  many  cases. 
The  exciting  cause  in  most  cases  is  an  influence  which  throws  the  heart 
into  violent  action,  as  an  unusual,  sudden  exertion,  shock,  or  such 
emotion  as  anger  or  fright.  An  attack  often  follows  overdistention  or 
sudden  gaseous  inflation  of  the  stomach,  or  chilling  of  the  body  as  by 
getting  out  of  bed  at  night. 

Theories  of  Angina. — The  exact  nature  of  the  disease  is  not  known. 
Many  interesting  theories  have  been  offered,  but  none  has  been  con- 
firmed. The  following  are  the  more  important  of  them  :  (i)  That  it  is 
a  neuralgia  of  the  cardiac  nerves  induced  chiefly  by  sclerosis  of  the 
coronary  arteries  or  by  changes  in  the  ganglia  within  the  heart  or  in 
the  pneumogastric  or  phrenic  nerve;  (2)  Heberden's  theory,  that  it  is 
a  cramp  of  the  heart  muscle,  now  regarded  as  highly  improbable;  (3) 
that  it  is  due  to  sudden  increase  of  tension  within  the  ventricles  due  to 
dilatation  (Traube  and  others) ;  (4)  Allan  Burns's  theory,  that  it  is 
due  to  ischemia  of  the  heart  muscle,  caused  by  disease  or  spasm  of  the 
coronary  arteries. 

Symptoms. — The  patient  is  suddenly  seized  with  a  most  agonizing 
pain  in  the  heart.  The  suff"ering  is  so  intense  that  he  is  rendered  motion- 
less. He  grasps  any  near  object  and  hangs  upon  it  as  if  for  support,, 
afraid  to  move  and  almost  afraid  to  breathe.  The  sensation  is  as 
though  the  heart  were  being  crushed  in  a  vise,  and  the  pain  radiates 
up  into  the  neck  and  down  the  left  arm,  sometimes  into  both  arms 
and  down  the  back.  Some  of  the  cervical  and  all  of  the  dorsal  areas 
to  the  ninth  may  be  included ;  generally  all  above  the  seventh  are  pain- 
ful, while  in  organic  disease  of  the  heart  and  in  aortic  aff'ections  only 
the  upper  four  are  usually  involved.  There  is  no  pain  so  intense,  no 
moment  so  full  of  anguish,  no  experience  so  terrifying.  The  face  becomes 
pale  and  ashen;  a  cold  sweat  starts,  and  the  patient  may  sink  in  a 
faint  from  which  he  does  not  recover,  or  death  may  be  instantaneous. 
It  is  a  remarkable  fact  that  the  heart's  action  may  be  little  disturbed 
during  the  attack;  its  action  may  be  full  and  regular,  but  the  radial 
pulse  is  generally  increased  in  tension  and  perhaps  in  force.  Some- 
times the  paroxysm  is  accompanied  with  distinct  bronchial  wheezing 
and  the  patient  may  experience  a  sensation  of  sufi"ocation.  Flatulent 
distention  of  the  stomach  is  an  almost  constant  symptom.  The 
seizure  generally  lasts  only  a  few  seconds  or  at  most  a  few  minutes.  It 
often  subsides  with  an  eructation  of  gas  from  the  stomach,  and  a  large 
quantity  of  clear  urine  is  often  voided,  as  after  other  nervous  par- 
oxysms. 

A  vasomotor  angina  has  been  described  in  which  the  cardiac  pain  is 
preceded  by  pallor,  coldness  and  cramping  of  the  limbs.  The  parox- 
ysms are  not  of  the  highest  grade  of  severity. 

Diagnosis. — In  a  well-marked  case  the  diagnosis  is  comparatively 
easy,  but  many  attacks  of  moderate  severity  may  occur  in  which  it  is 


368  PRACTICE  OF  MEDICINE 

extremely  difficult  to  decide  whether  the  seizure  is  one  of  true  angina 
or  of  pseudoangina,  a  name  applied  to  a  large  group  of  cases  not  con- 
forming to  the  description  just  given.  The  contrast  between  the  two 
conditions  is  sufficiently  clear,  however.  Bearing  in  mind  the  clinical 
picture  of  true  angina— a  primary  seizure  occurring  in  men  over  45, 
after  exertion,  excitement,  or  cold,  a  paroxysm  of  short  duration,  but 
attended  with  excruciating  pain  radiating  to  the  neck  and  arms,  render- 
ing the  patient  silent,  motionless,  and  breathless,  the  picture  of  despair — 
pseudoangina  is  characterized  by  very  different  features.  The  patient 
may  be  of  any  age,  often  a  woman  with  a  history  of  h}-steria,  the  attack 
often  recurring  periodically  and  perhaps  spontaneously  at  night,  lasting 
an  hour  or  two,  the  pain  less  severe,  and  the  patient  often  exhibiting 
violent  hysterical  or  nervous  movements.    It  is  never  fatal. 

Toxic  Angina. — Attacks  of  severe  pain  in  the  region  of  the  heart 
resembling  angina  pectoris  are  frequently  met  with  as  a  result  of  ex- 
cessive indulgence  in  tobacco,  less  frequently  from  coffee-  or  tea-drinking. 
The  pain  is  generally  paroxysmal  or  shooting  in  character,  wdth  irregu- 
lar, intermittent  palpitation  and  real  or  fancied  dyspnea.  The  patient 
is  usually  greatly  alarmed,  profuse  sweating  generally  occurs,  the  ex- 
tremities are  cold,  and  there  is  often  a  tendency  to  syncope  with  extreme 
weakness  of  the  circulation,  and  nausea.  The  attack  usualh^  lasts  several 
hours,  and  it  may  recur  at  increasingly  short  intervals  if  the  cause  be 
continued. 

Prognosis. — True  angina  pectoris  is  an  exceedingly  dangerous  af- 
fection, the  patient  often  dying  during  the  attack  or  with  equal  sud- 
denness and  without  warning  during  the  interval.  Pseudoangina,  on  the 
contrary,  is  never  fatal,  and  the  toxic  form  is  rarely  so. 

Treatment. — Prophylactic  treatment  is  important,  but  it  is  unfor- 
tunately very  limited.  Nothing  can  be  done  to  remove  the  sclerotic 
or  calcareous  condition  of  the  blood-vessels,  but  the  patient  may  be  re- 
moved from  the  usual  exciting  causes,  and  he  should  always  be  pro- 
vided with  the  most  efficient  remedies  for  the  relief  of  the  paroxysm, 
especially  with  the  perles  of  amyl  nitrite,  each  containing  3  or  5  drops, 
to    be  crushed  in  the  handkerchief  for  inhalation. 

The  treatment  of  the  attack  must  be  prompt.  Immediately  upon 
the  inception  of  the  pain,  the  patient  should  crush  a  perle,  and  inhale 
as  deeply  and  as  fully  as  possible  the  fumes  of  the  drug.  Unfortunately, 
however,  it  is  not  always  effective  and  occasionally  rather  increases  the 
suffocation.  A  few  drops  of  chloroform  inhaled  in  the  same  manner  may 
prove  more  effective,  but  in  some  cases  only  morphin  is  capable  of 
affording  relief.  This  too  must  be  given  in  increasing  dosage  if  often 
required.  Glonoin,  TT[j  (0.06),  hypodermically  is  sometimes  of  benefit. 
Either  hot  or  cold  appHcations  to  the  precordial  region  may  give  relief. 

In  the  intervals  the  most  careful  attention  should  be  given  to  the 
correction  of  any  abnormality  in  the  action  of  the  heart.  \Mien  the 
arterial  tension  is  high  it  may  be  reduced  wath  aconite  or  nitroglycerin, 
in  gradually  increasing  doses,  at  first  repeating  the  one-minim  dose 
three  times  during  the  day.  Sodium  nitrite  has  also  been  recommended. 
Potassium  brom.id  is  of  benefit  in  some  cases.  It  is  probably  only  in 
syphilitic  cases  that  decided  benefit  is  to  be  expected  from  a  prolonged 
course  of  potassium  iodid,   so  highly  recommended    by    some   writers. 


DISEASES  OF  THE  ARTERIES  369 

The  treatment  of  pseudoangina  should  be  directed  to  the  removal  of 
the  cause.  Tonics  are  generally  indicated.  The  existence  of  a  gouty 
taint  should  not  be  disregarded  in  either  form  of  angina. 

CONGENITAL  DEFECTS  OF  THE   HEART. 

A  great  majority  of  the  congenital  defects  of  the  heart  are  entirely 
devoid  of  clinical  interest ;  some  of  them  are,  in  fact,  incompatible  with 
life.  Occlusion  of  the  pulmonary  orifice,  with  patency  of  the  foramen 
ovale  and  perhaps  deficiency  of  the  ventricular  septum,  constitutes  the 
only  condition  likely  to  call  for  the  attention  of  the  physician. 

Symptoms. — Extreme  cyanosis  is  the  most  striking  symptom.  The 
infant  appears  blue,  especially  after  the  exertion  of  crying.  This  is 
generally  observed  as  early  as  the  second  week  of  life.  The  cyanosis 
may  be  general  or  it  may  be  confined  to  the  extremities.  If  life  be 
prolonged,  the  child  is  generally  poorly  developed,  in  part,  no  doubt, 
because  of  its  inability  to  engage  in  active  exercise.  The  activity  of 
play  renders  him  livid  and  produces  intense  dyspnea.  The  fingers  and 
toes  early  become  clubbed.  The  surface  of  the  body  is  always  cool. 
Cough  is  constantly  present.  Physical  examination  reveals  enlargement 
of  the  heart,  and  murmurs  are  heard  that  do  not  conform  to  any  recog- 
nized lesion  of  the  valves.  Increase  of  the  red  blood-corpuscles  is  a 
prominent  feature  and  sometimes  reaches  nearly  double  the  normal 
number  in  the  millimeter. 

Prognosis. — "  Blue  children"  rarely  live  to  puberty,  but  a  few  have 
been  known  to  attain  their  majority.  Death  may  result  from  the  de- 
fect or  from  an  intercurrent  disease,  especially  bronchopneumonia. 

Treatment. — The  child  should  be  protected  from  cold  and  other  in- 
fluences liable  to  increase  the  bronchial  congestion.  Venesection  may  be 
practiced  when  paroxysms  of  cyanosis  and  dyspnea  threaten  life.  The 
iaction  of  the  heart  may  be  to  some  extent  improved  by  the  adminis- 
tration of  digitalis  or  the  other  remedies  usually  employed  in  valvular 
disease. 

DISEASES  OF  THE  ARTERIES. 

ACUTE  AORTITIS. 

An  acute  inflammation  of  the  intima  of  the  aorta  similar  in  char- 
acter to  acute  endocarditis  and  often  associated  with  it. 

Etiology. — Whether  an  independent  affection  or  associated  with  en- 
docarditis, the  causes  are  practically  the  same  as  those  of  the  latter 
disease,  especially  rheumatism  and  the  other  acute  infectious  diseases; 
alcoholism,  lead-poisoning,  and  other  intoxications. 

Morbid  Anatomy. — The  intima  may  be  thickened,  hyperemic,  and  cov- 
ered with  a  layer  of  fibrin,  the  lesions  resembling  those  of  simple  endo- 
carditis, or  there  may  be  circumscribed  destruction  of  tissue  as  in  malig- 
nant endocarditis. 

Symptoms. — Pain  and  dyspnea  are  the  distinctive  features.    The  pain 

varies  from  a  sense  of  soreness  or  tenderness  beneath  the  sternum  to  a 

sharp  stabbing  along  the  arch  of  the  aorta  and  reflected  to  the  right 

shoulder.     Palpitation  is  sometimes  observed,  and  the  subclavians  may 

24 


3  70  PRACTICE  OF  MEDICINE 

be  felt  throbbing  above  the  clavicles.  Moderate  elevation  of  temper- 
ature usually  accompanies  the  attack.  The  acute  symptoms  generally 
subside  in  a  few  days,  but  the  inflammation  often  passes  over  into  a 
chronic  arteriosclerosis.  The  differential  diagnosis  from  endocarditis 
is  difficult,  resting  upon  the  greater  diffusion  of  the  pain  and  the  absence 
of  murmurs  indicative  of  valvular  involvement. 

The  prognosis  is  grave,  owing  to  the  possibility  of  embolism  or  rup- 
ture of  the  aorta. 

Treatment. — Absolute  rest,  with  light  diet,  and  an  ice-bag  over  the 
sternum,  are  the  principal  measures  of  relief.  Aconite  and  opium  may  be 
employed  for  the  dyspnea,  especially  when  the  heart's  action  is  rapid 
and  irregular.  When  fever  and  other  symptoms  of  sepsis  arise,  the  case 
should  be  handled  with  a  view  to  overcoming  that  condition. 

ARTERIOSCLEROSIS. 
Arteriocapillary  Fibrosis,  Atheroma. 

Definition. — A  degeneration  of  the  coats  of  the  arteries,  beginning 
in  the  intima,  followed  by  hyperplasia  of  the  connective  tissue  of  all 
the  coats,  and  terminating  in  contraction  and  rigidity,  greater  or  less 
deformity  of  the  vessel,  and  diminution  of  its  lumen.  The  impairment 
of  function  is  often  greatly  increased  by  subsequent  calcification. 

Etiology. — (i)  The  disease  is  rare  before  the  fortieth  year.  During 
the  declining  years  of  life  there  is  in  many  individuals  an  inherent  ten- 
dency to  this  hardening  of  the  arteries.  (2)  Men  are  more  subject  to 
it  than  women,  because  they  are  more  generally  exposed  to  the  other 
factors  of  its  production.  These  are  for  the  most  part  overwork,  worry, 
excitement,  malnutrition,  and  various  intoxications.  (3)  Notwithstand- 
ing these  influences,  however,  there  is  great  difference  in  individual  sus- 
ceptibility. Some  families  appear  to  be  predisposed  to  the  affection. 
The  predisposition  probably  depends  in  part  upon  an  inherited  type  of 
tissue  and  in  part  upon  similarity  in  the  habits,  food,  and  mode  of  liv- 
ing. The  disease  is  frequently  met  with  in  high-livers,  especially  those 
who  take  little  exercise  and  rapidly  accumulate  adipose  tissue.  Excessive 
consumption  of  meat  is  regarded  as  especially  influential  by  increasing 
the  nitrogenous  waste.  (4)  The  chronic  intoxications  most  likely  to  pro- 
duce the  affection  are  alcohol,  lead,  uric  acid,  and  those  of  syphilis  and 
other  diseases.  (^)  Alcohol  probably  acts  by  overstimulation  of  the 
heart,  disturbing  the  function  of  the  stomach,  liver,  and  kidneys,  and 
thus  increasing  the  production  of  waste  products  while  impeding  thieir 
elimination.  Uric  acid  and  lead  probably  act  directly  upon  the  tissues  of 
the  blood-vessels  and  to  some  extent  interfere  with  the  peripheral  cir- 
culation and  thus  increase  arterial  tension,  (^b^  Syphilis  operates 
chiefly  through  the  formation  of  gummatous  infiltration  of  the  vessel 
walls,  leading  directly  to  sclerosis.  Most  cases  occurring  in  early  life 
are  referable  to  this  influence.  (^)  The  other  diseases  generally  regarded 
as  influential  are  chronic  interstitial  nephritis,  tuberculosis,  chronic 
rhumatism,  diabetes,  and  malaria.  They  doubtless  operate  through 
the  production  of  toxic  matter  in  the  blood,  or  by  interfering  with  its 
elimination.  The  most  important  relation  in  the  latter  connection  is 
that    of  arteriosclerosis    with    chronic   interstitial    nephritis.    In  many 


DISEASES  OF  THE  ARTERIES  371 

instances  the  two  conditions  are,  no  doubt,  a  part  of  the  same  process, 
a  general  arteriosclerosis,  affecting  the  smaller  vessels  of  the  entire 
body;  but  in  another  group  of  cases  the  sclerotic  condition  of  the  kid- 
neys precedes  that  in  the  blood-vessels.  General  neuritis  and  other 
sclerotic  changes  in  the  nervous  system  are  sometimes  associated  with 
arteriosclerosis,  but  probably  as  a  result  of  the  same  influences,  and  not 
as  causal  factors. 

Morbid  Anatomy. — The  lesions  may  be  confined  to  the  aorta,  the  ves- 
sel most  frequently  affected,  or  they  may  be  more  or  less  uniformly 
distributed  throughout  the  arterial  system.  The  other  vessels  are  af- 
fected in  nearly  the  following  order  :  The  radial,  splenic,  iliac,  femoral, 
coronary,  cerebral,  brachial,  common  carotid,  vertebral,  and  the  periph- 
eral branches.  The  vessels  subjected  to  the  greatest  strain  are  gen- 
erally most  markedly  affected ;  those  of  the  alimentary  canal,  liver,  and 
mesentery  are  seldom  involved.  The  changes  sometimes  extend  beyond 
the  smaller  vessels,  into  the  capillaries,  and  rarely  also  into  the  veins. 
The  lesions  generally  conform  to  one  or  other  of  two  forms  designated 
circumscribed  or  diffuse. 

1.  Circumscribed  Arteriosclerosis. — Definite  areas  of  the  intima  become 
thickened  and  opaque.  These  are  often  hemispherical  in  form,  yellowish 
in  color,  and  they  are  more  frequently  situated  about  the  orifices  of 
the  branches.  Their  thickness  generally  bears  a  close  relation  to  their 
diameter  and  increases  with  it.  Histologically  the  change  begins  as  an 
infiltration  and  degeneration  of  the  middle  and  external  coats  of  the 
vessels,  especially  about  the  vasa  vasorum.  This  is  followed  by  a  thick- 
ening of  the  intima  as  a  compensatory  process  to  fill  the  slight  depres- 
sion that  would  otherwise  remain,  and  to  compensate  for  the  loss  of 
strength  in  the  vessel-wall.  The  thickening  is  followed  by  hyalin  degen- 
eration, however,  and  the  middle  tunic  is  often  found  in  a  state  of  gran- 
ular disintegration  or  necrosis  (atheromatous  abscess).  As  a  result  of 
this  weakening  of  the  walls  the  vessel  often  becomes  greatly  dilated,  and 
an  aneurism  may  be  formed.  In  some  cases,  however,  the  rapid  develop- 
ment of  connective  tissue  prevents  dilatation  and  by  subsequent  contrac- 
tion brings  about  a  diminution  of  the  caliber  of  the  vessel. 

2.  Diffuse  Arteriosclerosis. — The  intima  often  appears  smooth,  but  it 
may  show  nodular  prominences,  owing  to  the  association  of  the  circum- 
scribed form  of  the  disease.  This  is  usually  the  condition  found  in  the 
aorta.  On  section  of  the  vessel,  the  walls  are  found  to  be  greatly  thick- 
ened, the  greatest  increase  in  many  cases  affecting  the  intima.  Micro- 
scopic examination  reveals  a  highly  degenerated  media,  often  general 
in  character,  and  a  marked  proliferation  of  the  subendothelial  connective 
tissue.  The  muscular  and  elastic  tissues  are  sometimes  entirely  destroyed. 
Subsequent  degeneration  and  necrosis  of  the  media  follow,  and  calca- 
reous plates  are  often  formed  in  the  larger  vessels.  The  immediate  result 
of  the  sclerosis  is  to  diminish  the  elasticity  and  usually,  to  a  considerable 
extent,  the  lumen  of  the  vessel.  This  increases  the  resistance  to  the  flow 
of  blood  and  consequently  raises  the  arterial  tension.  More  work  is 
thrown  upon  the  heart,  and  the  response  is  a  hypertrophy  of  the  left 
ventricle.  The  more  remote  results  are,  diminished  supply  of  blood  to 
the  organs  and  tissues  through  the  affected  vessels,  with  consequent  im- 
pairment of  their  functions,  anemia  and  degeneration,  sclerosis  or  possibly 


372  PRACTICE  OF  MEDICINE 

necrosis.  Thrombosis  and  its  results  are  often  produced  by  arterio- 
sclerosis. 

Symptoms. — No  single  description  can  be  made  to  include  all  the  clin- 
ical manifestations  of  the  disease.  In  many  instances  the  condition  is 
in  fact  latent,  and  pronounced  lesions  are  found  after  death  in  persons 
who  had  made  no  complaint  leading  to  their  discovery.  The  manifes- 
tations are  peculiar  to  the  area  affected  and  the  extent  of  the  lesions. 
When  the  vessels  are  extensively  or  generally  involved,  an  increase  of 
arterial  tension  is  one  of  the  most  distinctive  features.  But  the  extent 
of  the  sclerosis  cannot  always  be  estimated  in  this  manner.  High  ten- 
sion is  recognized  for  the  most  part  by  its  effect  upon  the  pulse.  The 
wave  is  slow  in  ascent  and  descent,  and  the  artery  remains  full  between 
the  pulsations.  The  vessel  is  firm  and  so  hard  that  it  cannot  be  fully 
compressed  under  the  finger,  neither  is  it  possible  through  pressure  to 
entirely  overcome  the  pulse-wave.  Sometimes  the  calcification  of  the 
artery  becomes  so  extreme  that  the  pulse-wave  becomes  imperceptible. 
The  vessel  then  feels  hard  and  sometimes  rough.  Hypertrophy  of  the 
left  ventricle  is  produced  by  the  increased  work  thrown  upon  it.  It  is 
generally  a  simple,  pure  hypertrophy,  without  dilatation.  The  sounds 
are  little  disturbed,  except  that  the  aortic  second  sound  is  accentuated. 
The  aorta  becomes  markedly  dilated  in  some  cases,  causing  an  in- 
crease of  the  area  of  dullness  in  the  upper  sternal  region,  and  the  arch 
may  sometimes  be  felt  by  pressing  down  with  the  finger  in  the  supra- 
sternal notch.  The  increased  pressure  may  lead  to  an  increase  of  the 
quantity  of  urine  voided,  with  low  specific  gravity,  like  that  of  chronic 
interstitial  nephritis,  and  the  latter  condition  is,  indeed,  often  present. 
In  many  instances,  however,  the  general  health  of  the  individual  is 
little,  if  at  all,  impaired. 

Many  other  symptoms  are  occasionally  encountered  as  a  result  of 
secondary  degeneration  of  the  myocardium  or  in  the  region  most  in- 
volved in  the  arteriosclerosis.  Dyspnea,  precordial  uneasiness,  and  palpi- 
tation are  commonly  complained  of;  and  when  the  coronary  arteries 
become  involved  in  the  sclerosis,  as  they  frequently  do,  attacks  of  angina 
pectoris  supervene.  Late  in  the  disease  dilatation  of  the  heart  may 
succeed  to  the  hypertrophy,  and  a  train  of  symptoms  is  produced 
which  suggests  valvular  disease  with  loss  of  compensation.  A  murmur 
may  be  heard  at  the  apex  owing  to  relative  insufficiency  of  the  mitral 
valve,  the  arterial  tension  is  reduced,  the  second  aortic  sound  loses  its 
strong,  ringing  quality,  the  urine  becomes  scant,  and  serous  effusions 
may  occur.  The  true  nature  of  the  disturbance  cannot  well  be  deter- 
mined without  a  knowledge  of  the  previous  condition. 

Sclerosis  of  the  arteries  of  the  brain  excites  a  great  variety  of  symp- 
toms. Vertigo,  headache,  tinnitus,  melancholia,  insomnia,  aphasia, 
hemiplegia,  and  monoplegias  are  all  observed,  singly  or  in  various  com- 
binations, but  they  cannot  be  referred  with  accuracy  to  definite  lesions 
within  the  brain,  further  than  that  they  are  associated  with  the  dif- 
ferent lesions  of  arteriosclerosis,  including  miliary  aneurisms  and  their 
rupture.  When  the  vessels  of  the  spinal  cord  are  affected,  the  symptoms 
conform  with  more  or  less  exactness  to  chronic  myelitis,  multiple  sclero- 
sis, locomotor  ataxia,  syringomyelia,  or  general  paresis.  Involvement 
of  the  arteries  of  the  extremities  leads  to  numbness,  persistent  tingling, 


DISEASES  OF  THE  ARTERIES  373 

coldness  or  cramps,  purpuric  eruptions,  and  sometimes  to  thrombosis 
and  gangrene.  Finally,  arteriosclerosis  is  the  essential  element  in  the 
production  of  aneurisms  in  any  part  of  the  body. 

Diagnosis. — As  has  been  already  stated,  the  disease  may  be  so  ob- 
scure as  to  escape  recognition  during  life.  In  many  cases,  however,  its 
recognition  is  possible  if  search  be  made  for  it.  In  the  presence  of  indu- 
ration of  the  radial  and  temporal  arteries,  hypertrophy  of  the  heart, 
and  other  evidences  of  increased  arterial  tension,  as  shown  in  the  charac- 
ter of  the  pulse  and  the  accentuation  of  the  aortic  second  sound,  together 
with  other  evidences  of  premature  senility,  the  diagnosis  becomes  mani- 
fest, and  it  is  further  confirmed  by  the  discovery  of  renal  changes  and 
ossification  of  the  costal  cartilages.  The  calcification  of  the  arteries 
can  sometimes  be  distinctly  recognized  with  the  aid  of  the  X-ray.  After 
dilatation  of  the  heart  has  developed,  with  valvular  incompetency,  the 
diagnosis  is  obscured,  unless  the  hardness  of  the  peripheral  arteries  can 
be  felt  or  the  presence  of  calcareous  plates  can  be  recognized  in  the 
fiuoroscope. 

Prognosis. — The  disease  generally  progresses  slowly  and  leads  ulti- 
mately to  a  fatal  termination.  The  end  may  come  suddenly  through 
rupture  of  the  diseased  vessel  or  the  development  of  thrombosis  in  the 
coronary  arteries,  or  it  may  come  with  a  slowness  that  is  rendered 
burdensome  by  the  repeated  development  of  gangrene  in  the  extremities, 
or  by  gradual  wasting  and  extreme  feebleness.  Many  apparently  serious 
developments,  particularly  those  of  the  cerebral  group,  are  often  par- 
tially and  occasionally  completely  recovered  from. 

Treatment. — The  extent  to  which  the  progress  of  the  disease  can  be 
influenced  is  uncertain.  Good  might  be  accomplished  by  instruction  in 
the  regulation  of  the  diet  and  avoidance  of  the  causes  which  induce  the 
disease,  to  the  young  members  of  the  families  in  which  a  predisposition 
is  known  to  exist.  After  the  disease  has  been  recognized,  the  patient 
should  be  brought  to  realize  the  importance  of  abstemiousness  in  food 
and  drink,  regular  exercise,  the  avoidance  of  worry  and  excitement, 
strain  or  heavy  lifting,  and  probably,  above  all,  the  importance  of  main- 
taining a  regular  action  of  the  bowels  and  kidneys,  in  order  to  prevent 
the  accumulation  of  toxic  matters  in  the  system.  If  the  history  of 
syphilis  is  obtained,  a  vigorous  course  of  treatment  should  be  pursued. 
Potassium  iodid  is  regarded  by  some  writers  as  of  great  benefit  in  non- 
syphilitic  cases.  Large  doses  are  not  necessary.  For  the  symptoms 
due  to  increased  arterial  tension,  nitroglycerin  often  proves  beneficial. 
Blood-letting  is  probably  not  practiced  so  often  as  it  should  be  in  cases 
of  this  character,  for  it  affords  a  positive  means  of  warding  off,  for  a 
time  at  least,  the  serious  results  of  extreme  distention  of  the  weakened 
vessels. 

ANEURISM. 

Definition.— A.  circumscribed  dilatation  of  an  artery.  Classification: 
(i)  A  true  aneurism  is  one  in  which  the  wall  is  formed  of  one  or  more 
of  the  tunics  of  the  vessel.  (2)  The  so-called  false  aneurism  is  a  blood- 
sac  formed  by  the  rupture  of  all  the  coats  of  the  vessel,  and  the  reten- 
tion of  the  blood  in  the  surrounding  tissues.  (3)  An  arteriovenous 
aneurism  is  formed  by  the  establishment  of  a  communication  between 


374  PRACTICE  OF  MEDICINE 

an  artery  and  a  vein.  When  a  sac  is  formed  between  the  artery  and 
vein,  it  is  known  as  a  varicose  aneurism ;  but  when  the  communication 
is  direct  and  the  dilatation  is  composed  principally  of  the  vein,  it  is 
called  an  aneurismal  varix.  (4)  The  dissecting  aneurism  is  one  in  which 
the  dilatation  is  formed  between  the  coats  of  the  vessel-wall  as  a  result 
of  perforation  of  the  intima.  (5)  In  situation,  aneurisms  are  axial 
when  they  involve  the  entire  circumference  of  the  vessel,  and  peripheral 
when  they  are  confined  to  a  side  of  the  vessel.  (6)  In  form,  they  are 
cylindrical,  saccular,  fusiform,  or  circoid,  the  latter  term  being  applied 
to  the  dilatation  of  an  artery  and  its  branches.  (7)  The  term  miliary 
aneurism  designates  a  small,  often  microscopic  dilatation,  usually  present 
in  large  numbers,  in  the  course  of  a  vessel,  especially  in  the  brain.  (8) 
External  aneurisms  are  sometimes  referred  to  as  surgical,  and  internal 
as  medical. 

Etiology. — Congenital  aneurisms  are  very  rarely  met  with,  and  they 
are  generally  multiple.  In  adults  they  usually  develop  between  the  ages 
of  30  and  50,  and  much  more  commonly  in  men.  The  aorta  is  more 
frequently  involved  than  any  other  vessel,  but  complete  exemption  can 
hardly  be  claimed  for  any  of  the  arteries.  The  frequency  of  the  disease 
in  the  aorta  is  greatest  immediately  above  the  heart,  and  diminishes  in 
an  almost  constant  ratio  with  the  distance  from  the  heart.  The  same 
rule  applies  to  its  branches. 

All  cases  of  aneurism  depend  upon  a  natural  or  acquired  weakness 
of  the  arterial  walls.  In  a  great  majority  of  cases  it  is  a  result  of:  Qa) 
Arteriosclerosis  with  its  consequent  weakening  of  the  media  or  of  all 
the  tunics.  Q~)  The  most  frequent  predisposing  cause  is  syphilis,  which 
is  recognizable  in  about  7  5  per  cent  of  the  cases.  Alcohol  is  doubtless 
another.  (^)  Sometimes  it  is  attributed  to  trauma,  as  a  fall  upon  the 
back.  (^)  \'\^ittaker  emphasizes  the  importance  of  the  strain  upon  the 
vessels  occasioned  by  hard  work,  in  connection  with  the  other  influences. 
Unusually  sudden  pressure,  like  that  caused  in  lifting,  athletic  exercises, 
or  strong  emotion,  has  been  regarded  as  the  exciting  cause  in  some 
cases.  Qe)  Aneurism  occasionally  follows  the  lodgment  of  an  embolus. 
The  degeneration  of  the  vessel-wall  is  sometimes  directly  due  to  the 
embolus.  (/)  In  a  number  of  cases  multiple  aneurisms  have  been  traced 
to  the  action  of  pyogenic  bacteria  derived  from  a  malignant  endocarditis 
or  other  suppurative  focus  (mycotic  aneurism). 

Symptoms.— The  clinical  manifestations  depend  so  much  upon  the 
location  and  size  of  the  aneurism  that  few  general  statements  can  be 
made.  The  distinctive  features  of  a  fully  developed  aneurism  in  a  part 
accessible  to  inspection  and  palpation  are  those  of  a  tumor  with 
expansile  pulsation,  a  thrill  and  double  murmur,  often  transmitting 
the  heart-sounds  and  producing  pressure  symptoms  of  various  kinds. 
But  these  symptoms  may  one  or  all  be  absent.  Only  the  pressure  symp- 
toms and  the  bruit  are  generally  observed  in  internal  aneurisms,  until 
the  sac  has  become  so  large  as  to  produce  erosion  of  the  overlying 
tissues  or  to  render  its  pulsation  recognizable  through  them. 

Aneurism  of  the  Aorta.— The  symptoms  vary  with  the  part  of  the 
vessel  affected  and  the  location  of  the  dilatation  with  reference  to  sur- 
rounding viscera,  whether  on  the  anterior,  posterior,  or  lateral  surface 
of  the  artery. 


DISEASES  OF  THE  ARTERIES  375 

Pain  is  one  of  the  earliest  and  most  constant  symptoms  in  deep- 
seated  aneurisms,  often  occurring  in  paroxysms  of  great  severity,  like 
those  of  angina.  It  is  most  severe  in  rapidly  enlarging  tumors,  and 
after  the  pressure  becomes  so  great  as  to  cause  erosion  of  the  vertebrae, 
ribs,  or  sternum.  Cough  is  produced  by  pressure  on  the  trachea  or 
bronchi,  and  a  bronchitis  is  often  developed,  with  abundant  watery 
expectoration,  becoming  purulent  and  more  viscous.  Dyspnea  is  common, 
especially  when  the  transverse  portion  is  affected.  It  may  be  due  to 
pressure  on  the  left  bronchus,  the  trachea,  or  the  recurrent  laryngeal 
nerve,  usually  the  left.  Hoarseness  or  aphonia  accompanies  the  dyspnea, 
as  a  rule,  when  it  depends  upon  this  nerve  pressure,  since  it  causes  spasm 
or  paralysis  of  the  muscles  controlling  the  vocal  cord  of  the  affected 
side.  Hemorrhage  is  sometimes  induced  by  the  pressure  on  the  bronchus 
or  by  the  congestion  of  the  lung.  A  slow  oozing  of  blood  preceding  for 
a  short  time  the  final  rupture  of  the  sac  sometimes  occasions  more  or 
less  distinct  hemoptysis,  or  the  blood  may  accumulate  in  the  stomach, 
to  finally  induce  vomiting  and  rupture  of  the  aneurism  in  the  effort. 
When  rupture  occurs,  there  is  generally  a  profuse  gush  of  blood,  followed 
by  instant  death.  The  rupture  often  occurs,  however,  into  one  of  the 
thoracic  cavities  or  into  the  esophagus,  and  there  is  no  visible  indication 
of  it.  Compression  of  the  esophagus  sometimes  causes  obstruction,  and 
deglutition  becomes  difficult  or  impossible.  The  aneurism  has  been, 
perforated  in  attempts  to  pass  the  esophageal  bougie.  The  thoracic  duct 
may  also  be  compressed.  Pressure  on  the  sympathetic  nerves  causes 
dilatation  or  contraction  of  one  pupil.  Pressure  on  the  veins  causes 
engorgement,  especially  of  the  head  and  arms.  Pallor  of  one  cheek  is 
sometimes  noted. 

Physical  Signs. — Inspection. — Pulsation  can  generally  be  detected  by 
close  examination  in  a  good  light.  It  is  in  most  cases  seen  in  the  right 
second  intercostal  space,  sometimes  in  the  left,  or  it  may  be  seen  in  the 
suprasternal  notch  when  the  transverse  portion  and  the  innominate  are 
involved.  As  the  tumor  increases  in  size,  bulging  becomes  manifest. 
It  can  be  seen  best  by  looking  across  the  chest  or  downward  over  the 
shoulder.  The  protrusion  generally  involves  the  first  and  second  right 
interspaces  and  sometimes  a  part  of  the  sternum,  or,  if  the  sac  is  imme- 
diately above  the  heart,  it  may  cause  bulging  of  the  third  interspace 
close  to  the  left  of  the  sternum.  Aneurism  of  the  descending  portion 
seldom  causes  bulging,  but  it  may  cause  prominence  of  the  second  or 
third  left  interspace  or  rarely  of  the  left  scapular  region. 

After  erosion  has  become  complete,  a  pulsating  tumor  appears,  cov- 
ered only  by  the  skin,  which  becomes  hyperemic  and  may  slough  so  as 
to  expose  the  external  surface  of  the  sac.  The  impulse  of  the  heart  is 
often  displaced  downward  as  a  result  of  pressure,  and  may  be  strong  at 
either  the  right  or  left  of  the  sternum.  The  apex  beat  is  correspond- 
ingly  low  and  often  beyond  the  left  mammary  line. 

Palpation. — The  pulsation  is  strong,  usually  heaving,  and  expansile. 
When  the  tumor  has  not  reached  a  size  to  be  grasped  in  the  hand,  the 
expansile  quality  can  sometimes  be  recognized  by  pasting  strips  of  paper 
over  it  and  noting  their  separation  with  each  systolic  impulse;  or  it 
may  become  perceptible  when  one  hand  is  placed  over  the  prominence 
and  the  other  on  the  spine.    A  sharp  diastolic  shock  can  sometimes  be 


376  PR.\CTICE  OF  MEDICL\E 

felt,  especially  in  aneurism  at  the  root  of  the  aorta.  It  is  synchronous 
with  the  closure  of  the  aortic  valves,  and  a  valuable  sign.  A  systolic 
thrill  or  fremitus  is  more  generally  felt  over  a  large  dilatation  of  the 
aorta  than  over  a  saccular  one. 

Tracheal  tugging  is  a  valuable  sign  when  it  can  be  obtained.  It  is 
elicited  by  having  the  patient  sit  erect  with  his  mouth  closed  and  the 
chin  elevated  almost  to  the  full  extent,  the  head  resting  against  the 
breast  of  the  examiner,  standing  behind  him.  The  cricoid  cartilage  is 
then  grasped  between  the  finger  and  thumb  and  gently  but  steadily 
drawn  upward.  If  the  aorta  be  dilated,  its  pulsation  can  now  be  dis- 
tinctly felt,  transmitted  through  the  trachea  to  the  fingers. 

Percussion. — A  deep-seated  aneurism  produces  no  perceptible  change; 
but  when  the  tumor  reaches  the  chest-wall  or  causes  bulging,  a  peculiar 
flat  note  and  resistance  can  be  recognized  that  are  unlike  those  of  a  con- 
solidated portion  of  lung.  The  flat  area  varies  with  the  situation  of 
the  tumor;  it  is  on  the  right  side  of  the  sternum  in  an  aneurism  of  the 
ascending  portion;  under  the  upper  part  of  the  sternum  and  to  the 
left  in  that  of  the  transverse  portion,  and  usually  in  the  left  interscap- 
ular and  scapular  regions  in  that  of  the  descending  portion. 

Auscultation. — A  murmur  is  usually  heard,  but  it  may  be  absent  even 
in  aneurisms  of  large  size  when  the  layer  of  fibrin  on  the  interior  of 
^the  sac  is  thin  or  presents  a  smooth  internal  surface.  It  is  systolic  in 
time  and  is  transmitted  along  the  blood-vessels  so  as  to  be  heard  in 
the  neck  and  along  the  course  of  the  aorta,  but  with  greater  intensity 
immediately  over  the  tumor,  corresponding  to  the  area  of  flatness  on 
percussion.  It  is  often  accompanied  by  an  aortic  regurgitant  bruit, 
which  gives  the  impression  of  a  double  murmur,  and  it  is  then  a  more 
characteristic  sign  than  when  it  occurs  alone,  denoting,  as  a  rule,  an 
aneurism  at  the  root  of  the  aorta.  The  murmur  of  regurgitation  may 
be  heard  when  the  aneurismal  systolic  bruit  is  absent.  A  systolic  bruit 
can  sometimes  be  heard  over  the  trachea  or  at  the  open  mouth.  It  is 
perhaps  due  to  the  expulsion  of  air  from  the  lung  by  the  expansion  of 
the  aneurismal  sac. 

The  Pulse.— Vi^d^Y  of  the  pulse  in  the  vessels  beyond  the  aneurism  is 
a  sign  of  great  value  in  many  cases.  A  distinct  interval  can  be  rec- 
ognized between  the  time  of  the  radial  pulses,  as  well  as  a  diminution  of 
the  volume  of  the  one  on  the  affected  side.  Osier  observed  a  complete 
obliteration  of  the  pulsation  in  the  abdominal  aorta  and  its  branches  in 
a  case  of  very  large  aneurism  situated  on  the  descending  portion  of  the 
thoracic  aorta.  Ophthalmoscopic  examination  may  reveal  strong  pulsa- 
tion of  the  retinal  vessels  on  the  affected  side,  and  little  or  none  on  the 
other  side. 

Diagnosis. — The  recognition  of  the  aneurism  becomes  difficult  when 
(^a)  the  sac  is  deep-seated  and  of  small  size.  There  may  be  only  a  feel- 
ing of  discomfort  within  the  thorax,  but  periodical  pain  radiating  to 
the  left  shoulder  is  often  of  significance,  especially  if  other  pressure 
symptoms,  as  cough,  dyspnea,  and  bronchitis,  be  present.  (/;)  Aneurism 
of  the  ascending  portion  of  the  arch  has  been  called  the  aneurism  of 
physical  signs,  and  that  of  the  transverse  portion  the  aneurism  of  symp- 
toms; the  latter  is  always  more  difficult  of  recognition.  Pressure 
symptoms  are  generally  produced,  but  they  are  not  sufficiently  distinctive 


DISEASES  OF  THE  ARTERIES  377 

of  the  affection.  In  some  cases  the  manifestations  are  observed  only 
periodically.  («)  Another  class  of  cases  is  rendered  obscure  by  the  pre- 
dominance of  symptoms  on  the  part  of  the  respiratory  system  sug- 
gesting bronchitis  or  bronchiectasis.  It  is  sometimes  possible  in  such 
cases,  by  laryngoscopic  examination,  to  recognize  the  compression  of 
the  trachea  or  a  beginning  paralysis  of  the  vocal  cord.  The  principal 
affections  to  be  excluded  in  arriving  at  a  diagnosis  are  abnormally 
strong  pulsation  of  the  aorta,  pulsating  empyema,  and  solid  tumors. 
Violent  throbbing  of  the  aorta  is  generally  secondary  to  aortic  in- 
sufficiency. The  pulsation  of  an  empyema  is  not  expansile  and  there 
is  no  bruit  or  diastolic  shock;  the  pulsation  is  generally  diffused  over 
the  chest.  Solid  tumors  with  transmitted  pulsation  are  sometimes 
differentiated  with  difficulty,  but  the  pulsation  is  quite  different  to  the 
touch,  and  it  is  not  expansile.  The  shock  is  also  absent.  In  deep- 
seated  tumors,  however,  owing  to  the  similarity  of  the  pressure  symp- 
toms, a  differential  diagnosis  may  be  impossible.  The  most  valuable 
signs  are  the  absence  of  murmur,  of  the  ringing  aortic  second  sound, 
and  tracheal  tugging.  The  X-ray  has  proved  a  valuable  aid  to  diagnosis 
in  obscure  cases. 

Prognosis. — There  are  few  diseases  of  more  serious  import  than  tho- 
racic aneurism,  and  yet  spontaneous  recovery  is  possible.  Even  when 
complete  recovery  does  not  occur,  many  years  of  comfort  may  be  se- 
cured, but  there  is  ever  hanging  over  the  patient  the  possibility  of  a 
sudden  rupture  of  the  weakened  aortic  wall.  Death  usually  ensues  from 
rupture  of  the  sac,  but  occasionally  from  other  diseases  induced  by  the 
aneurism  or  from  asthenia. 

Treatment. — A  large  aneurism  can  be  treated  only  by  palliative 
measures,  relieving  the  suffering  with  morphin  and  retarding  the  ultimate 
issue  by  rest  and  the  avoidance  of  exertion,  excitement,  and  worry. 
When  the  aneurism  has  been  discovered  early,  measures  may  be  taken 
to  promote  the  coagulation  of  blood  and  contraction  of  the  sac.  The 
treatment  to  be  employed  is  absolute  rest  of  body  and  mind  and 
restriction  of  diet.  Fluids  should  be  sparingly  ingested  and  all  stim- 
ulants should  be  avoided.  The  Tufnell  diet  represents  the  extreme  re- 
striction that  may  be  attempted,  but  it  is  generally  found  to  be  too 
severe.  The  patient  is  allowed,  for  breakfast  and  supper,  bread  and 
butter,  2  ounces ;  milk,  2  ounces ;  and  for  dinner,  meat  and  bread,  each 
2  to  3  ounces;  and  milk  or  claret,  2  to  4  ounces.  The  best  results  are 
obtained  in  cases  of  saccular  aneurism.  If  the  heart's  action  continue 
rapid  or  if  palpitation  occur,  aconite  may  be  employed  or  an  ice-bag 
may  be  applied  over  the  tumor.  Glonoin,  gtt.  j  to  ij  t.  i.  d.,  is  often 
serviceable;  and  when  dyspnea  and  angina  are  present  amyl  nitrite  may 
be  very  cautiously  inhaled.  Potassium  iodid  is  the  most  valuable 
remedy,  however,  both  for  the  relief  of  pain  and  the  reduction  of  the 
tumor.  It  should  be  given  in  doses  of  gr.  x  to  xx  (0.60 — 1.20)  t.  i.  d. 
The  possibility  of  obtaining  benefit  from  surgical  methods  should  always 
be  considered,  although  the  results  in  thoracic  aneurism  have  seldom  been 
satisfactory.  Electrolysis  is  safer  than  such  measures  as  the  introduction 
of  wire  or  hair,  and  has  been  followed  by  excellent  results  in  certain  cases. 

Aneurism  of  the  Abdominal  Aorta.— The  dilatation  usually  affects 
the  portion  of  the  vessel  immediately  below  the  diaphragm,   near  the 


378  PRACTICE  OF  MEDICINE 

celiac  axis,  and  sometimes  involving  it  also.  It  is  more  commonly  fusi- 
form than  saccular. 

Symptoms. — A  dull,  aching  pain,  reflected  to  the  back  and  flanks,  is 
generally  the  principal  symptom,  but  it  may  be  absent.  When  the 
tumor  extends  forward,  it  may  produce  prominence  of  the  epigastrium 
or  left  hypogastrium ;  when  backward,  it  erodes  the  bodies  of  the  verte- 
brae. Numbness  and  tingling  of  the  legs  are  then  produced,  and  para- 
plegia may  follow.  Pressure  symptoms  may  be  noted,  at  least  vomiting, 
or  the  pressure  may  be  exerted  upon  the  intestines,  liver,  spleen,  or 
kidneys.    The  femoral  pulse  is  retarded  and  reduced  in  volume. 

Physical  Signs. — Prominence  and  pulsation  may  be  recognized  in  one 
of  the  regions  referred  to  by  both  inspection  and  palpation.  The  pul- 
sation is  expansile,  sometimes  double,  and  a  thrill  may  be  felt.  An  area 
of  dullness  may  be  recognizable,  and  a  soft  murmur  may  be  heard,  but 
the  diastolic  shock  and  systolic  murmur  are  absent. 

Diagnosis.— The  epigastric  pulsation  is  sometimes  so  strong  in  neuras- 
thenic or  extremely  anemic  women  as  to  suggest  aneurism.  But  there 
is  no  expansile  tumor,  and  the  physical  signs  are  absent.  Pulsation  may 
be  transmitted  through  a  solid  tumor  in  the  abdomen,  as  in  the  thorax, 
but  again  it  lacks  the  force,  the  expansile  quality,  and  the  thrill.  The 
tumor  usually  loses  its  pulsation  when  the  patient  is  placed  in  the  knee- 
elbow  position,  which  allows  the  growth  to  gravitate  away  from  the  aorta. 

The  prognosis  is  unfavorable.  Spontaneous  recovery  has  been  reported 
in  a  few  instances,  but  a  vast  majority  of  the  cases  are  fatal  through 
(<3!)  rupture,  (^)  complete  obliteration  of  the  lumen  by  clots,  (<:)  para- 
plegia, or  (^)  embolism  of  the  mesenteric  artery. 

The  treatment  is  the  same  as  that  of  thoracic  aneurism.  Compres- 
sion of  the  vessel  above  the  tumor  has  been  practiced,  but  seldom  with 
benefit  and  repeatedly  with  serious  or  fatal  results. 

Aneurism  of  the  celiac  axis  may  be  associated  with  aneurism  of  the 
abdominal  aorta,  as  stated.  It  is  rarely  a  primary  aff^ection.  The 
hepatic,  mesenteric,  splenic,  and  renal  arteries,  being  less  subject  to 
sclerosis,  are  seldom  the  sites  of  aneurism,  and  when  aff'ected  the  con- 
dition is  not  usually  diagnosticated  during  life.  They  frequently  rupture 
before  attaining  appreciable  size. 

DISEASES  OF  THE   MEDIASTINUM. 

In  this  group  are  included  inflammatory  processes  and  tumors  of  the 
tissues  and  glands  in  the  mediastinal  spaces,  including  affections  of  the 
thymus  gland. 

Inflammation. — This  may  affect  either  the  lymph-glands  (lymphade- 
nitis) or  the  fibrous  tissue  (mediastinitis) ;  it  may  be  simple,  suppurative, 
or  tubercular.  Tubercular  mediastinitis  is  generally  accompanied  with 
suppuration. 

Etiology. — i.  Simple  inflamtnatioii  arises  chiefly  from:  (i^)  Penetrating 
wounds  and  injuries  by  foreign  bodies  in  the  esophagus,  (Jb^  by  exten- 
sion from  inflammatory  processes  in  the  bronchi  or  lungs,  especially 
the  bronchitis  or  bronchopneumonia  attending  measles  or  other  acute 
infection,  and  sometimes  (J)  by  extension  from  the  pleura  or  pericardium. 

2.   Suppurative  infiamniation  arises  :   (d)  By  extension  along  the  blood- 


DISEASES  OF  THE  MEDIASTINUM  379 

vessels  from  the  tissues  of  the  neck,  including  the  larynx,  trachea,  and 
esophagus,  or  from  the  retropharyngeal  abscess  in  children,  ((^)  from 
suppuration  in  the  lungs,  thymus  or  bronchial  glands ;  (<r)  from  trauma, 
as  fracture  of  the  sternum,  wounds  or  burns  of  the  neck ;  (^)  from  per- 
foration of  an  esophageal  ulcer  or  diverticulum;  and  (^)  probably  by 
metastasis  in  pyemia,  erysipelas,  typhoid  and  typhus  fevers,  pneumonia, 
or  smallpox. 

3.  Tubercular  mediastinitis  usually  results  through  extension  from  a 
tubercular  process  in  the  vertebrae  or  lymph-glands. 

Tumors. — The  most  important  of  these  are  cancer  and  sarcoma.  Of 
the  520  cases  of  mediastinal  disease  collated  by  Hare,  134  were  carcino- 
mata,  98  sarcomata,  21  lymphomata,  7  fibromata,  11  dermoid  cysts, 
and  8  hydatid  cysts.  The  most  frequent  points  of  origin  were  the 
thymus  and  lymph  glands,  the  pleura  and  the  lung.  Men  were  more 
frequently  affected,  and  the  age  was  generally  between  30  and  40. 

Morbid  Anatomy. — Simple  inflammation  is  often  attended  with  the 
throwing  out  of  plastic  lymph  about  the  vessels,  nerves,  and  bronchi. 
This,  becoming  organized,  forms  firm  adhesions  and  constricting  bands 
(plastic  mediastinitis).  Subsequent  contraction  of  the  adventitious 
bands  leads  to  constriction  of  the  blood-vessels  and  bronchi  in  some 
cases.  In  the  suppurative  form  a  greater  or  less  quantity  of  pus  is 
found  in  either  of  the  mediastinal  spaces,  and  in  many  cases  it  has  bur- 
rowed from  its  original  source  into  adjacent  structures.  One  or  more 
of  the  ordinary  pus-forming  bacteria  may  be  discovered  in  it.  Ulceration 
and  perforation  often  occur,  more  commonly  into  the  esophagus  or 
bronchial  tubes,  occasionally  into  the  pleura,  pericardium,  peritoneal 
cavity,  or  externally. 

Symptoms. — (i)  The  manifestations  of  a  simple  mediastinitis  are  often 
concealed  by  those  of  the  affection  to  which  they  owe  their  origin. 

Pressure  symptoms  are  common  to  all  forms  of  mediastinal  disease, 
though  less  pronounced  in  simple  inflammation  than  in  abscess  or 
tumor.  Prominent  among  them  are  :  (a;)  Cough,  which  is  usually  parox- 
ysmal, resembling  pertussis,  but  continuing  indefinitely  and  probably 
due  to  pressure  upon  the  trachea  at  its  bifurcation;  or  in  some  cases 
to  pressure  on  the  recurrent  laryngeal  nerve,  when  hoarseness  is  also 
present,  (^b^  Dyspnea,  often  so  extreme  as  to  suggest  compression  of 
the  vagus,  a  possible  condition,  but  more  probably  due  to  compression 
of  the  bronchi.  Cyanosis  of  the  face  and  neck  and  an  audible  wheezing 
respiration  usually  accompany  the  cough  and  dyspnea  in  severe  cases, 
(t-)  Engorgement  of  the  jugular  veins,  which  is  most  marked  during 
inspiration,  and  the  pulsus  paradoxus  of  Kussmaul,  in  which  the  radial 
pulse  becomes  almost  imperceptible  during  inspiration.  The  apex  im- 
pulse and  sounds  are  also  feeble.  (^)  There  is  generally  a  sense  of 
weight,  aching,  or  acute  pain  beneath  the  sternum,  and  the  pain  some- 
times radiates  to  the  back  or  sides  of  the  chest  and  to  the  shoulders. 
(^)  More  or  less  complete  dysphagia  may  be  present,  and  a  constriction 
may  sometimes  be  recognized  in  the  passage  of  the  esophageal  bougie. 
(/)  Other  occasional  symptoms  are  epistaxis,  vomiting,  cardiac  palpita- 
tion, clubbing  of  the  fingers,  weak  voice,  hoarseness  or  complete  aphonia, 
ascites,  edema  of  the  legs.  Systolic  bruits  are  sometimes  heard  on 
auscultation  over  the  aorta  and  pulmonary  arteries.     Pupillary  changes, 


38o  PRACTICE  OF  MEDICINE 

particularly  inequality,  are  sometimes  occasioned  by  pressure  upon  the 
sympathetic. 

(2)  In  abscesses  of  the  mediastinum  there  is  usually  added  to  these 
symptoms  tenderness  to  pressure  over  the  sternum,  a  more  or  less  con- 
stant elevation  of  temperature,  and  other  manifestations  of  sepsis.  Other 
symptoms  are  produced  which  are  more  or  less  common  to  tumors  in 
this  region.  Many  obscure  symptoms  sometimes  arise  from  rupture  of 
the  abscess,  but  the  pressure  symptoms  promptly  subside  and  thus  give  a 
suggestion  of  the  nature  of  the  disease.. 

(3)  75/;«^rj-.— During  the  growth  of  a  tumor  in  the  mediastinum 
many  of  the  symptoms  that  have  been  enumerated  are  more  or  less 
prominently  developed.  Yet  in  some  cases  the  tumor  acquires  a  con- 
siderable growth  without  producing  definite  disturbances.  A  distinct 
pulsation  is  often  transmitted  through  a  soHd  tumor  or  tense  abscess. 
Bulging  of  the  sternum  and  erosion  are  sometimes  observed,  or  the 
tumor  may  cause  a  prominence  above  or  at  the  side  of  the  sternum. 
A  cachexia  develops  in  all  malignant  cases.  Percussion  elicits  dullness 
over  the  affected  area,  which  is  often  most  easily  recognized  posteriorly. 
Auscultation  reveals  for  the  most  part  an  absence  of  heart  and  respira- 
tory sounds  over  the  area  of  dullness,  but  when  the  trachea  or  bronchi 
are  compressed  there  is  usually  a  prolongation  of  inspiration  and  expi- 
ration, with  high  pitched,  tubular  quality.  When  a  bronchus  has  been 
completely  closed,  there  are  the  usual  signs  of  pulmonary  collapse  over 
the  area  supplied  by  it.  Pleural  effusion  is  often  found  in  the  dependent 
portion  of  the  chest. 

Diagnosis.— \t  is  often  difficult  to  determine  the  exact  nature  of  the 
disease.  Septic  manifestations  point  to  the  existence  of  an  abstess,  and 
cachexia  is  no  less  significant  of  malignant  disease.  Sarcoma  is  more 
frequently  primary  than  is  carcinoma,  and  it  is  oftener  situated  in  the 
anterior  mediastinal  space.  But  the  differentiation  of  these  growths  is 
often  based  upon  the  age  of  the  patient  and  the  presence  of  a  primary 
growth  in  some  other  region. 

Aneurism  is  often  excluded  with  difficulty,  for  there  are  no  absolutely 
distinctive  signs.  As  a  rule,  its  growth  is  much  slower  than  that  of 
cancer  or  sarcoma,  the  pain  is  sharper  and  more  uniformly  present 
and  it  radiates  more  commonly  to  the  back,  neck,  and  down  the  arm. 
The  pulsation  is  stronger  and  more  expansile  than  that  of  an  abscess  or 
other  tumor,  and  a  distinct  diastolic  shock  can  generally  be  recognized, 
both  on  auscultation  and  palpation.  A  downward  movement  of  the 
larynx  with  the  pulsations  of  the  tumor  (tracheal  tugging)  is  strongly 
indicative  of  aneurism.  Finally,  a  distinct  bruit  is  usually  heard,  which 
is  more  forcible  and  quite  unlike  that  transmitted  through  a  solid  tumor. 

The  prognosis  is  grave  in  abscess,  and  invariably  fatal  in  malignant 
disease. 

Treatment. — Abscesses  can  sometimes  be  successfully  opened  and 
drained  after  resection  of  a  part  of  the  sternum.  The  possibility  of 
syphilis  should  always  be  borne  in  mind  in  obscure  cases,  and  a  brief 
course  of  treatment  employed.  When  this  fails  and  when  the  case  is 
beyond  the  reach  of  the  surgeon,  palliative  treatment  alone  remains. 
Morphin  should  be  freely  given  in  order  to  render  the  patient  as  com- 
fortable as  possible. 


SECTION  V. 
Diseases  of  the  Respiratory  System. 


DISEASES  OF  THE  NOSE. 


ACUTE  CORYZA. 

ACUTE  RHINITIS,   ACUTE  NASAL  CATARRH. 

Definition. — An  acute  inflammation  of  the  mucous  membrane  of  the 
nose. 

Etiology. — The  disease  is  beHeved  to  be  of  microbic  origin.  In  many 
cases  a  sudden  change  of  temperature,  exposure  to  cold  and  wet  or 
irritating  fumes,  is  believed  to  aid  infection.  The  disease  attacks  individ- 
uals of  any  age ;  it  is  most  frequent  in  the  autumn  and  spring.  It  often 
appears  to  be  contagious  and  sometimes  assumes  epidemic  prevalence. 

Symptoms. — The  attack  is  often  initiated  with  chilly  sensations,  and  a 
sense  of  fullness  and  pain  in  the  head,  repeated  sneezing,  often  with  rise 
of  temperature,  not  usually  exceeding  ioi°  F.  (38.5°  C),  and  aching* 
of  the  limbs  and  back.  The  mucous  membrane  of  the  nose  becomes 
dry  and  swollen,  and  the  patient  is  compelled  to  breathe  through  the 
mouth.  There  is  sometimes  a  severe  aching  pain  in  one  or  both  nos- 
trils. Within  a  few  hours  a  watery  secretion  is  established  which  irritates 
the  edges  of  the  nostrils  and  requires  the  constant  application  of  the 
handkerchief.  Eczema  of  the  lip  is  often  produced,  and  nasal  or  labial 
herpes  may  appear.  The  sense  of  smell  is  obtunded,  and  to  some  ex- 
tent that  of  taste.  The  lachrymal  ducts  are  involved,  and  there  is  a 
flow  of  tears.  The  inflammation,  extending  to  the  throat,  produces 
soreness,  tinnitus,  and  partial  deafness.  The  pharynx  and  larynx  are 
usually  inflamed.  Sometimes  the  nasal  sinuses  are  affected  and  produce 
the  most  intense  pain  in  the  forehead  or  face,  preventing  sleep  or  masti- 
cation. By  the  second  or  third  day  the  secretion  becomes  mucopurulent 
and  more  tenacious.  Its  quantity  then  diminishes,  the  swelling  subsides, 
constitutional  symptoms  disappear,  and  nasal  respiration  is  re-estab- 
lished. Recovery  is  complete  in  a  week  or  ten  days.  Repeated  attacks 
render  the  individual  more  susceptible  and  may  produce  a  chronic  ca- 
tarrhal condition.     Many  subacute  cases  occur. 

Diagnosis.— The  condition  is  readily  recognized.  When,  however,  the 
initial  symptoms  are  severe,  and  particularly  if  the  temperature  exceed 
101°  F.,  the  possibility  of  its  being  a  prodrome  of  an  acute  infection, 
particularly  measles  or  influenza,  should  be  borne  in  mind.  Nasal  catarrh 
(snuflles)  in  an  infant  is  highly  suggestive  of  syphiUs.  A  watery  dis- 
charge from  only  one  nostril  may  indicate  the  presence  of  a  foreign 
body.  The  ingestion  of  iodin  produces  a  condition  like  coryza  in  a 
susceptible  person. 


3«2 


PRACTICE  OF  MEDICINE 


The  prognosis  is  fayorable  except  in  the  extremes  of  life,  when  there 
is  danger  of  extension  of  the  catarrh  to  the  bronchial  tubes. 

Treatment. — Infants  and  old  persons  should  be  kept  indoors  and 
confined  to  bed  during  a  severe  attack.  Robust  persons  seldom  need 
restraint  except  when  fever  is  present.  The  patient  should  then  be  put 
to  bed  and  given  hot  drinks,  especially  lemonade,  and  a  full  dose  of 
Dover's  powder  at  bedtime.  Sweating  should  be  encouraged  by  a  heavy 
covering  of  blankets.  A  saline  cathartic  should  be  given  immediately 
upon  awaking  in  the  morning.  Nothing  affords  greater  relief  during 
the  daytime  than  small  doses  of  Dover's  powder,  gr.  j  to  iij  (0.06 — 0.18), 
with  extract  of  belladonna,  gr.  ^  to  ^  (0.005 — o.oi),  every  two  or  three 
hours  until  the  nasal  secretion  has  reached  the  mucopurulent  stage. 
When  the  sinuses  are  involved,  hot  applications  should  be  employed.  A 
Turkish  bath  often  cuts  short  an  attack. 


CHRONIC  NASAL  CATARRH. 

CHRONIC  RHINITIS. 

There  are  three  forms  of  chronic  nasal  catarrh,  designated,  according 
to  the  character  of  their  lesions,  simple,  hypertrophic,  and  atrophic. 

Etiology. — The  disease  may  result  from  repeated  attacks  of  coryza, 
from  long  subjection  to  a  smoky  or  dusty  atmosphere.  Bad  hygiene, 
malnutrition,  and  deficient  clothing  favor  it,  and  there  is  great  difference 
of  individual  susceptibility.  In  many  persons,  however,  it  is  largely  due 
to  asymmetry  of  the  chambers  from  deviation  of  the  septum,  or  to  the 
presence  of  adenoids,  polypi,  or  foreign  bodies.  The  disease  may  be 
syphilitic  or  tuberculous  in  its  origin. 

1.  Simple  Rhinitis. — The  mucous  membrane  is  thick  and  hyperemic, 
secreting  a  large  quantity  of  clear  or  yellow  tenacious  mucus  which 
causes  obstruction  and  interference  with  respiration. 

2.  Hypertrophic  rhinitis  presents  greater  swelling  of  the  mucous 
membrane,  particularly  over  the  turbinated  bones,  and  is  often  associ- 
ated with  adenoid  growths  in  the  nasopharynx.  There  is  increased 
secretion  of  mucus,  generally  purulent  and  tenacious.  Mouth-breathing 
is  induced  with  consequent  dryness  of  the  throat,  hawking  and  coughing, 
and  a  nasal  tone  of  voice. 

3.  Atrophic  Rhinitis. — The  mucous  membrane  of  the  nasal  cavity 
becomes  thin,  and  the  cavity  correspondingly  larger,  but  the  mucus 
accumulates  and  forms  thick,  hard  crusts  that  sometimes  remain  in 
position  until  ulceration  occurs  beneath  them.  There  is  then  an  offensive 
fetid  discharge  (coryza  fetida).  The  term  ozena  is  also  applied  to  the 
condition,  particularly  when  the  necrosis  extends  to  the  bone.  Ozena 
is  generally  due  to  tuberculosis  or  syphilis.  The  sense  of  smell  is  lost, 
taste  is  impaired,  the  hearing  becomes  defective,  and  constant  noises 
are  often  complained  of.  The  disease  usually  occurs  in  early  life  and  is 
more  frequent  in  women. 

Treatment. — Hygienic  measures  are  of  value,  the  patient  should  be 
instructed  with  reference  to  proper  ventilation,  bathing,  and  exercise, 
A  change  of  climate  is  often  advisable  in  those  having  a  tuberculous 
tendency.      In   the   hypertrophic    and  atrophic  forms,  treatment  by  a 


HAY  FEVER  ^83 

si>ecialist  is  generally  necessary.  Cleanliness  of  the  affected  mucous 
membranes  is  essential.  This  can  be  accomplished  by  sniffing  from  the 
hand  or  allowing  to  flow  into  the  nostrils  a  warm  alkaline  solution. 
Seiler's  tablets  may  be  used,  or  a  solution  may  be  made  with  a  dram 
each  of  salt  and  bicarbonate  of  soda  in  four  ounces  of  warm  water. 
The  engorgement  of  the  mucous  membrane  may  be  greatly  relieved  in 
many  instances  by  frequent  spraying  with  a  solution  of  menthol,  3  ss 
(2.0);  camphor,  gr.  xx  (1.3);  in  liquid  albolin    ^  ij  (60.0). 

HAY  FEVER. 

AUTUMNAL  CATARRH,   HAY  ASTHMA,  ROSE  COLD. 

Definition. — A  catarrhal  affection  of  the  upper  respiratory  passages, 
with  asthmatic  breathing,  generally  attributed  to  irritation  of  the  mu- 
cous membranes  by  vegetable  dust  or  pollen. 

Etiology. — The  disease  generally  prevails  in  August  and  September, 
but  it  is  occasionally  contracted  in  the  spring.  Men  are  a  little  more 
frequently  attacked  than  women.  The  disease  is  more  common  in  the 
United  States  than  in  Europe,  and  more  prevalent  in  cities  than  in  the 
country.  Only  certain  individuals  are  affected,  and  in  these  there  is 
generally  some  abnormal  condition,  as  deviation  of  the  nasal  septum, 
polypi,  or  hypertrophy  of  the  turbinated  bones,  to  account  for  their 
susceptibility.  Most  patients  are  also  distinctly  neurotic,  and  a  heredi- 
tary tendency  often  appears.  An  attack  has  been  induced  in  a  suscep- 
tible person  by  suggestion,  with  an  artificial  rose. 

Dunbar  has  recently  discovered  that  the  pollen  of  rye,  oats,  wheat, 
rice,  corn,  and  all  other  forms  of  grass  contains  an  albuminoid  sub- 
stance which  is  capable  of  producing  all  the  symptoms  of  hay  fever  in 
a  susceptible  person  at  all  times  of  the  year,  whether  it  be  applied 
locally  to  the  nasal  mucous  membrane  or  introduced  subcutaneously. 

Symptoms. — The  same  individual  is  generally  attacked  at  the  same 
time,  often  on  the  same  day,  of  each  year.  The  onset  is  announced  by 
persistent  sneezing,  or  the  patient  may  be  seized  during  the  night  with 
an  asthmatic  attack.  The  condition  quickly  becomes  one  of  severe 
coryza,  to  which  are  added  paroxysms  of  coughing  and  more  or  less 
frequent  asthmatic  seizures.  The  patient  is  rendered  unfit  for  business, 
is  generally  greatly  depressed  and  often  melancholy. 

Diagnosis. — The  diagnosis  is  generally  evident.  Asthma  of  other 
origin  is  not  attended  with  coryza  or  so  great  mental  depression. 

Prognosis. — The  disease  seldom  results  seriously,  but  relief  from  the 
attack  and  removal  of  the  tendency  are  alike  difficult. 

Treatment. — The  attack  is  relieved  in  most  cases  by  a  visit  of  six 
weeks  to  the  mountains.  The  seashore  is  better  in  some  cases,  and  a 
sea-voyage  gives  relief  to  all.  When  such  means  are  unavailable,  medic- 
inal treatment  must  be  applied.  Irrigation  of  the  nose  with  a  solution 
of  quinin,  gr.  j  (0.06),  to  water,  3  ij  (60.0),  has  been  recommended. 
Spraying  the  nostrils  with  a  solution  of  adrenalin  hydrochlorid  (i  :5ooo 
or  less)  has  been  recommended.  More  is  generally  to  be  accomplished 
by  treatment  of  the  patient  in  the  intervals  than  during  the  attacks. 
The  nasal  chambers  should  be  carefully  examined  by  a  specialist,  and 


384  PRACTICE  OF  MEDICINE 

abnormal  conditions  remedied.  The  neurotic  condition  calls  for  the  ad- 
ministration of  tonics,  particularly  strychnin,  and  iron  or  arsenic.  Dun- 
bar believes  that  he  has  succeeded  in  producing  a  curative  serum. 

EPISTAXIS. 

NOSE-BLEED. 

Etiology. — The  causes  are  local  and  constitutional,  (i)  Among  the 
former  are  injury,  blows,  rubbing,  picking,  coughing,  sneezing,  the 
lodgment  of  a  foreign  body,  or  the  presence  of  neoplasms.  The  presence 
■of  chronic  nasal  catarrh  favors  its  occurrence. 

(2)  The  principal  constitutional  causes  are:  ((?)  Arterial  engorge- 
ment, so-called  plethora,  or  the  hyperemia  which  sometimes  attends  the 
invasion  of  an  acute  infection.  (^)  Venous  engorgement,  particularly 
when  it  is  due  to  an  advanced  valvular  heart  disease.  (^)  Abnormal 
states  of  the  blood,  as  hemophilia,  purpura,  scurvy,  pernicious  anemia, 
or  leukemia.  (^)  Sudden  reduction  of  atmospheric  pressure,  as  in  ascend- 
ing to  great  altitudes.  (^)  Vicarious  menstruation  and  cessation  of 
chronic  hemorrhoidal  bleeding  are  possible  causes ;  and  (_/")  mental  emo- 
tion may  induce  it.  The  source  of  the  blood  is  generally  a  capillary 
oozing  from  the  septum,  floor,  or  outer  wall. 

Symptoms. — There  is  sometimes  a  prodromal  sensation  of  fullness  or 
throbbing,  but  the  bleeding  often  starts  without  warning.  Except  in 
abnormal  blood-states,  it  is  generally  confined  to  one  side.  If  the  bleed- 
ing occur  at  night,  the  blood  may  be  swallowed  during  sleep  and  vom- 
ited later.  The  quantity  of  blood  lost  is  generally  less  than  an  ounce, 
but  in  severe  hemorrhages  it  may  be  so  great  as  to  produce  syncope. 
As  this  condition  comes  on,  the  blood  ceases  to  flow.  Death  rarely 
results  from  epistaxis,  but  the  patient  may  be  left  in  an  anemic  and 
debilitated  condition,  especially  if  he  be  the  subject  of  nephritis  or  heart 
disease. 

Treatment. — Moderate  epistaxis  is  often  beneficial,  even  in  the  passive 
congestion  of  heart  disease.  When  it  is  necessary  to  interfere,  the  bleed- 
ing spot  should  be  found,  if  possible,  and  subjected  to  pressure  or  cauteri- 
zation. If  this  cannot  be  done,  ice  may  be  applied  to  the  nose  and  ice- 
water  sniff"ed  or  douched  into  it.  Hot  water  is  equally  effective.  Astrin- 
gent solutions  may  be  employed,  as  alum  or  zinc  (2  to  4  per  cent). 
Solutions  of  iron  or  tannin  are  sometimes  effective,  but  they  are  exceed- 
ingly uncleanly.  Pledgets  of  cotton  may  be  dipped  into  the  solutions 
or  impregnated  with  the  astringent  powder  and  introduced.  When 
these  measures  are  ineffectual,  the  posterior  nares  should  be  plugged, 
and,  this  failing,  the  entire  nasal  chamber  should  be  firmly  packed  with 
pledgets  of  cotton  or  gauze  threaded  on  a  string.  The  tampon  must 
not  remain  longer  than  48  hours.  Treatment  of  the  constitutional 
condition  should  not  be  overlooked. 

NASAL  NEUROSES. 

.IS  term  is  applied  chiefly  to  alterations  of  the  sense  of  smell.     These 
are  :  (<3;)  Anosmia,  or  a  more  or  less  complete  loss  of  smell ;  {F)  hyper- 


LARYNGITIS  385 

osmia,  or  an  abnormally  acute  sense  of  smell;  and  (^)  parosmia,  in 
which  the  sense  is  altered  or  perverted.  The  affections  are  generally- 
attributed  to  alterations  in  the  nerve-endings  in  the  Schneiderian  mem- 
brane that  may  result  from  any  of  the  forms  of  inflammation.  Besides 
these,  injury  and  disease  of  the  fifth  nerve  may  be  followed  by  a  loss  of 
the  reflexes,  so  that  sneezing  is  no  longer  induced  by  irritation. 


DISEASES    OF    THE    LARYNX 
ACUTE  LARYNGITIS. 

Eiiology. — The  disease  may  be  primary  or  secondary;  primary  as  a 
result  of  atmospheric  conditions,  or  "cold,"  inhalation  of  irritating 
dust  or  fumes,  injury  by  foreign  bodies,  or  excessive  speaking;  secondary 
in  connection  with  the  acute  infections,  catarrh  of  the  nose  or  throat, 
or  when  associated  with  pulmonary  disease. 

Symptoms. — There  is  generally  a  sense  of  tickling  or  pain  in  the 
larynx  aggravated  by  the  inhalation  of  cold  air  and  sometimes  !by 
swallowing;  a  cough  which  may  be  "croupy,"  and  huskiness  of  the 
voice.  Dyspnea  is  often  produced  in  children  and  may  result  from 
associated  edema  in  adults.  On  examination  the  mucous  membrane  is 
found  to  be  hyperemic,  the  condition  involving  the  vocal  cords,  but 
most  pronounced  in  the  aryepiglottic  folds.  There  are  usually  no  con- 
stitutional disturbances  in  an  uncomplicated  case,  except  occasionally 
slight  fever  in  children. 

Diagnosis. — The  differentiation  is  generally  to  be  made  from  spas- 
modic, diphtheritic,  and  edematous  laryngitis.  In  spasmodic  laryngitis 
the  paroxysm  comes  on  suddenly,  and  it  subsides  completely  without 
hoarseness  or  pain.  It  is  purely  a  nervous  condition.  Diphtheritic  or 
membranous  laryngitis  is  generally  accompanied  with  a  similar  disease  of 
the  tonsils  or  pharynx,  and  there  is  a  history  of  possible  contagion  in 
most  cases.  The  cervical  glands  are  generally  enlarged  and  the  illness 
is  more  severe.  In  edema  of  the  glottis  there  is  greater  dyspnea,  and 
examination  reveals  the  condition. 

Treatment. — The  patient,  particularly  if  a  child,  and  when  fever  is 
present,  should  be  confined  to  bed  in  a  warm  room.  The  air  should  be 
kept  moist  by  the  evaporation  of  water,  and  steam  may  be  inhaled. 
Hot  or  cold  applications  over  the  larynx  are  beneficial.  The  larynx 
must  be  given  rest,  speaking  being  forbidden.  Dover's  powder  at  night 
and  ammonium  chlorid  and  ipecacuanha  or  squill  during  the  day  are 
the  principal  remedies.    Aconite  may  be  given  for  the  fever. 

CHRONIC  LARYNGITIS. 

Etiology. — Repeated  attacks  of  acute  laryngitis,  persistent  overuse 
of  the  voice  in  the  open  air,  and  the  inhalation  of  irritating  dust  or 
tobacco  smoke  are  the  most  frequent  causes.  Diseases  of  the  nose  and 
pharynx  often  lead  to  laryngitis. 

Symptoms  and  Diagnosis. — There  is  pronounced  hoarseness,  some- 
times amounting  to  aphonia,  sometimes  pain  and  soreness,  and  more  or 

25 


386  PRACTICE  OF  MEDICINE 

less  constant  tickling  and  cough.  The  local  signs  of  inflammation  may 
be  slight,  yet  enough,  as  a  rule,  to  distinguish  it  from  tuberculosis  of  the 
larynx,  in  which  the  appearance  is  one  of  anemia.  Ulceration  does  not 
occur,  except  in  late  tuberculosis  or  in  syphilis. 

Treatment.— The  larynx  must  be  given  rest;  tobacco  and  alcohol 
must  be  abstained  from,  and  other  causative  agencies  removed.  Inhala- 
tions of  steam,  sprays  of  menthol  and  camphor,  afford  relief.  Silver 
nitrate  and  other  remedies  may  be  employed,  but  these  and  the  treat- 
ment of  the  nose  and  pharynx,  which  is  sometimes  necessary,  would 
better  be  intrusted  to  a  specialist. 

EDEMATOUS  LARYNGITIS. 

EDEMA  OF  THE  GLOTTIS. 

Etiology. — («)  Any  disease  attended  with  general  dropsy,  especially 
nephritis  and  cardiac  disease ;  (<5)  acute  infections,  especially  diphtheria, 
scarlet  fever,  smallpox ;  (^)  chronic  disease  of  the  larynx ;  (df )  injury  by 
vapors,  hot  fluids,  or  poisons ;  (^)  repeated  attacks  of  acute  laryngitis, 
are  the  most  common  causes,  (y)  An  angioneurotic  origin  has  been 
referred  to. 

Symptoms. — A  sudden,  urgent  dyspnea  develops,  increasing  in  sever- 
ity until  the  face  becomes  livid,  the  voice  is  lost,  the  heart's  action 
becomes  tumultuous,  and,  if  continuing  for  24  to  36  hours,  sometimes 
earlier,  death  may  appear  imminent.  A  fatal  termination  sometimes 
occurs.  Examination  reveals  the  swelling,  particularly  in  the  aryepi- 
glottic  folds;  sometimes  it  is  deeper  in  the  larynx  (subglottic).  The 
prognosis  is  always  serious. 

Treatment. — If  the  symptoms  be  not  urgent,  cold  may  be  applied 
externally  and  pieces  of  ice  may  be  held  in  the  mouth,  but  in  most 
cases  the  edematous  swelling  should  be  scarified  without  delay,  the 
larynx  being  first  sprayed  with  cocain  (4  per  cent).  If  this  fail,  tra- 
cheotomy must  be  performed. 

NEUROSES  OF  THE  LARYNX. 

SPASM  OF  THE  LARYNX. 

Laryngismus  Stridulus,  Spasmodic  Laryngitis. 

Two  forms  of  spasm  of  the  larynx  are  recognized,  one  a  spasm  of 
the  adductor  muscles  without  inflammation,  usually  occurring  in  early 
infancy  and  doubtless  a  pure  neurosis  (laryngismus  stridulus) ;  the 
other  occurring  in  later  childhood  as  a  result  of  catarrhal  inflammation 
(spasmodic  croup). 

I.  Laryngismus  Stridulus.— This  form  is  more  frequent  in  male  infants 
between  the  ages  of  six  months  and  two  years.  The  attacks  are  usually 
attributed  to  reflex  irritation,  particularly  from  the  gastrointestinal 
tract.  They  are  especially  common  in  rachitic  infants  and  those  affected 
with  cerebral  or  spinal  disease.  Spasm  of  the  larynx  may  occur  in 
adults  also  as  a  manifestation  of  hysteria,  or  as  a  result  of  the  inhala- 
tion of  irritating  fumes,  the  lodgment  of  a  foreign  body,  tubercular  or 
syphilitic  ulceration. 


BRONCHITIS  387 

Symptoms. — The  attack  commonly  occurs  at  night.  The  child  awakes 
struggHng  for  breath.  Respiration  has  ceased.  The  face  is  livid,  and  the 
struggle  may  assume  the  appearance  of  a  convulsion,  or  a  convulsion 
may  actually  occur;  but  in  a  moment  the  spasm  relaxes,  with  a  long 
crowing  inspiration.  The  attack  may  recur  several  times  during  the 
night,  and  even  during  the  daytime,  or  at  intervals  of  several  days  for 
a  week  or  longer.  There  is  no  cough,  hoarseness,  or  other  evidence  of 
catarrh.  Death  has  occurred  in  feeble  infants  or  as  a  result  of  cerebral 
hemorrhage  induced  by  the  attack. 

Treatment.— Tht  attack  is  usually  too  short  to  require  treatment. 
In  the  interval,  however,  search  should  be  made  for  the  cause  of  the 
irritation ;  errors  of  diet  should  be  corrected,  the  bowels  regulated,  and 
the  rachitic  or  other  underlying  condition  treated.  Fresh  air,  sunshine, 
exercise,  and  cold  sponging  all  assist  in  overcoming  the  abnormal  excita- 
bility of  the  nervous  system. 

Spasmodic  Croup.— This  is  a  more  frequent  affection  and  occurs  in 
weakly  or  robust  children  between  2  and  6  years  of  age.  The  child 
awakes  suddenly  during  the  night,  generally  after  midnight,  gasping 
for  breath;  or  a  loud,  hoarse  cough  may  be  the  first  indication  of  the 
condition.  The  voice  is  hoarse  and  the  respirations  are  sonorous.  Cya- 
nosis may  be  produced,  but,  as  a  rule,  the  paroxysm  subsides  within  a 
half-hour  and  the  child  falls  asleep,  to  awake  in  the  morning  entirely 
free  from  it,  or  perhaps  still  a  little  hoarse.  The  attack  may  be  repeated 
on  several  succeeding  nights.     The  prognosis  is  good. 

Treatment. — The  paroxysm  may  be  relieved  by  a  few  inhalations  of 
chloroform,  by  an  emetic,  by  the  inhalation  of  steam  discharged  from  a 
convenient  vessel  under  an  improvised  tent,  or  by  a  hot  mustard-bath. 
When  the  hoarseness  continues  during  the  day,  a  cough  sirup  containing 
ammonium  chlorid  and  sirup  of  ipecacuanha  should  be  prescribed. 

Other  Neuroses.— Chief  among  these  are  hyperesthesia,  anesthesia, 
paresthesia,  and  hysterical  aphonia.  True  paralysis  of  the  vocal  cords 
is  encountered  chiefly  as  a  result  of  diphtheria,  the  growth  of  tumors 
in  the  larynx  or  in  a  situation  where  they  press  upon  the  recurrent 
laryngeal  nerve,  as  is  the  case  with  aneurisms  of  the  arch  of  the  aorta. 

Tubercular  laryngitis  is  considered  under  the  head  of  Tuberculo- 
sis (p.  190).  Syphilitic  laryngitis  is  referred  to  under  the  head  of 
Syphilis  (p.  165). 

DISEASES    OF    THE    BRONCHI. 
ACUTE  BRONCHITIS. 

Definition.— An  acute  inflammation  affecting  the  mucous  membrane 
of  the  bronchial  tubes  of  large  and  medium  size.  A  similar  affection  of 
the  smaller  tubes,  known  as  capillary  bronchitis,  is  considered  under  the 
head  of  Bronchopneumonia. 

Etio/ogy.— The  disease  is  probably  of  microbic  origin.  Atmospheric 
conditions,  especially  cold  and  excessive  moisture,  sudden  changes  of 
temperature,  and  the  presence  of  dust  or  irritant  vapors  doubtless  exert 
a  predisposing  influence.  The  disease  is  often  caused  by  direct  extension 
of  inflammation  or  infection  from  the  nose  or  pharynx.     It    may    be 


388  PRACTICE  OF  MEDICINE 

secondary  also  to  other  diseases,  particularly  to  measles,  malaria,  ty- 
phoid fever,  and  other  infections.  The  predisposing"  causes  are  many, 
especially  :  (^a^  Age.  The  disease  is  more  common  in  early  and  late  life; 
heredity  is  often  an  important  factor.  (^)  Habits;  indoor,  sedentary 
life  without  exercise.  (^)  Poverty  and  privation.  (dT)  Occupations 
which  necessitate  the  breathing  of  dusty  air.  (^)  General  health,  but 
particularly  the  presence  of  pulmonary  disease,  as  tuberculosis;  or  a 
gouty  diathesis.  (7^)  Climate  and  season.  The  disease  is  much  more 
common  in  changeable  climates  and  in  the  winter  season. 

Morbid  Anaiomy. — The  essential  lesions  are  hyperemia,  swelling,  and 
increased  secretion,  and  these  are  found  in  the  mucous  membrane  of  the 
trachea  as  well  as  in  that  of  the  bronchial  tubes.  The  disease  is  gen- 
erally a  tracheobronchitis.  Desquamation  of  epithelium  occurs,  and  the 
submucosa  becomes  to  some  extent  hyperemic  and  edematous.  The 
bronchial  lymph-glands  are  generally  enlarged  and  hyperemic. 

Symptoms. — The  onset  may  be  sudden  or  gradual;  it  is  generally 
preceded  by  coryza,  except  in  individuals  alread}-  affected  with  pulmonary 
disease.  There  is  generally  a  slight  chilliness,  rarel}'  a  rigor,  with  languor 
and  aching  of  the  limbs  and  back.  Fever  follows  in  the  more  severe 
cases,  especially  in  children,  but  it  seldom  exceeds  103°  F.  (39.5°  C), 
and  the  pulse  is  rapid.  A  dry,  harsh,  paroxysmal  cough  develops,  and 
during  the  paroxysms  the  patient  often  experiences  a  sharp  pain  behind 
the  sternum  and  through  the  chest.  Headache  may  also  be  present. 
The  cough  soon  gives  rise  to  a  scant,  viscid  expectoration;  this  in  a 
few  days  becomes  mucopurulent,  then  purulent  and  more  abundant. 
The  cough  now  becomes  less  painful  and  the  fever  subsides.  In  infants 
the  bronchial  secretion  is  not  expectorated  and  there  may  be  little  cough. 
The  disease  must  be  recognized  in  them  through  the  dyspnea,  rapid 
respiration,  and  fever,  with  the  physical  signs  that  are  always  present. 
In  the  aged,  too,  the  disease  often  begins  insidiously,  with  prostration, 
rapid  respiration,  and  even  delirium,  with  but  little  cough.  At  either 
extreme  of  life  there  is  great  danger  of  extension  to  the  finer  bronchi. 

Diagnosis. — The  disease  is  readily  recognized  upon  physical  examina- 
tion, if  not  by  the  general  symptoms  present.  In  robust  individuals  of 
middle  age,  little  is  to  be  observed  on  inspection.  In  the  infant  and 
old  person,  however,  the  respiratory  movements  become  rapid,  and,  in 
the  former,  there  may  be  slight  sinking  of  the  intercostal  spaces  during 
inspiration.  The  upper  part  of  the  thorax  sometimes  appears  expanded 
and  the  lower  part  depressed.  In  adults  the  dyspnea  and  acceleration 
of  breathing  correspond  to  the  degree  of  fever.  The  bronchial  fremitus 
can  sometimes  be  felt.  Percussion  seldom  furnishes  exact  information 
in  a  case  of  simple  bronchitis. 

On  auscultation,  numerous  rales  are  heard.  In  the  beginning  these 
are  of  a  dry  character,  sibilant,  or  sonorous,  but  later  there  are  moist, 
mucous  rales.  They  are  heard  intermittently,  coughing  causing  them 
to.  disappear  for  a  time,  as  a  rule,  but  they  are  distinctly  audible  in  all 
parts  of  the  chest,  though  with  greater  distinctness  in  some  regions 
than  in  others.  Sometimes  the  disease  is  confined  almost  exclusively  to 
one  side,  especially  when  it  is  a  complication  of  tuberculosis.  The 
vesicular  murmur  is  disturbed  in  rhythm^  and  pitch.  Both  inspiration 
and  expiration  are  prolonged,   expiration   more  than  inspiration,-. and 


BRONCHITIS  389 

the  pause  is  shortened.  The  pitch  is  raised.  The  sputum  is  not  al- 
together distinctive  in  character.  After  the  disease  has  fully  developed, 
it  consists  largely  of  pus,  in  which  alveolar  cells  are  found  in  greater  or 
less  numbers  and  in  different  degrees  of  degeneration. 

The  features  which  especially  distinguish  simple  bronchitis  from  other 
affections  are,  the  character  of  the  rales  and  their  general  distribution. 
Bronchopneumonia  and  acute  tuberculosis  are  chiefly  to  be  excluded. 
In  the  former,  fine  moist  rales  are  heard  along  the  margins  and  at  the 
base  of  the  lungs.  The  prostration  and  dyspnea  are  greater.  In  acute 
general  tuberculosis,  the  high  temperature,  great  prostration,  night- 
sweats,  and  other  symptoms  rarely  fail  to  distinguish  it  from  acute 
bronchitis. 

Prognosis. — Acute  bronchitis,  of  itself,  is  seldom  a  serious  disease  in 
middle  life,  but  in  the  very  aged  and  the  infant  it  should  always  be  so 
regarded.  It  may  terminate  fatally  in  these  patients  through  asphyxia 
or  exhaustion,  and  the  danger  of  its  extending  to  the  finer  tubes  and 
producing  a  bronchopneumonia  is  always  a  great  one. 

Treatment. — In  mild  cases  in  persons  of  middle  age  the  disease  may 
generally  be  relieved  or  greatly  modified  by  the  administration  of  hot 
lemonade,  a  hot  foot-bath,  and  a  full  dose  of  Dover's  powder  at  the 
time  of  retiring  for  the  night.  In  severe  cases,  the  patient  should  be  kept 
in  bed.  A  saline  cathartic  should  be  given  in  the  morning.  A  mus- 
tard-plaster applied  to  the  chest  relieves  the  pain  behind  the  sternum. 
The  air  of  the  patient's  room  should  be  warm  and  moist.  A  Turkish 
bath  sometimes  proves  of  the  greatest  benefit,  providing  the  patient 
can  remain  over  night  in  the  bath-house;  otherwise  it  is  unsafe,  on 
account  of  the  exposure  that  must  follow  it.  A  full  dose  of  quinin 
(gr.  X — XX ;  0.60 — 1.2)  at  night  benefits  some  cases.  A  mixture  con- 
taining ammonium  chlorid  or  potassium  acetate  (gr.  j — ij;  0.06 — 0.12) 
and  sirup  of  ipecacuanha  (TT[ij — v;  0.15 — 0.3)  in  each  dose,  with  con- 
finement to  bed,  is  generally  all  that  is  required  for  a  child  in  an  uncom- 
plicated case.  The  compound  sirup  of  squill  is  often  employed.  Senega 
and  wild-cherry  assist  in  checking  the  secretion  in  the  later  stage  of  the 
disease.  An  emetic  is  often  effective  in  clearing  out  the  bronchial  tubes 
when  obstructed  to  such  a  degree  as  to  cause  alarming  cyanosis.  Inha- 
lations of  steam  impregnated  with  the  vapor  of  benzoin,  eucalyptus,  or 
turpentine  is  often  beneficial.  The  vapor  may  be  inhaled  through  a 
paper  funnel  inverted  over  a  pitcher  containing  a  quart  of  boiling  water 
to  which  a  dram  of  the  medicament  has  been  added.  In  the  extremes 
of  life,  attention  must  be  given  to  the  general  nutrition  of  the  patient, 
and  stimulants  should  generally  be  given  in  quantity  suitable  to  the 
age  and  physical  condition. 

CHRONIC  BRONCHITIS. 

Etiology. — Chronic  bronchitis  may  result  from  repeated  attacks  of  the 
acute  form,  but,  as  a  rule,  it  runs  a  subacute  course  from  the  beginning 
and  is  directly  attributable  to  disease  of  the  lungs  or  other  organs. 
Among  diseases  of  the  lungs,  the  most  commonly  bearing  a  causative 
relation  are  tuberculosis,  emphysema,  asthma,  chronic  interstitial  pneu- 
monia, and  chronic  pleurisy  with  adhesions.    Among  diseases  of  other 


390  PRACTICE  OF  MEDICINE 

organs,  valvular  heart  disease,  and  nephritis  are  the  most  important. 
The  disease  is  much  more  frequent  in  persons  past  middle  life,  but  it 
is  often  encountered  in  the  young.  It  is  often  spoken  of  as  the  "  winter 
cough"  of  old  people,  beginning,  as  it  does,  with  the  first  onset  of  cold 
weather  and  continuing  until  summer  returns.  It  is  much  more  preva- 
lent in  cold  and  changeable  climates,  and  especially  near  the  seacoast. 

Morbid  Anaiomy. — The  changes  are  not  constant.  In  some  cases  the 
mucosa  and  muscular  layers  are  found  in  a  state  of  atrophy,  in  some 
they  are  thickened  and  infiltrated.  The  surface  of  the  mucosa  may  be 
granular,  smooth,  and  in  places  destitute  of  epithelium,  or  ulcerated. 
Bronchiectatic  dilatations  are  common  in  cases  of  long  standing.  Em- 
physema is  always  present. 

S/mpfotns. — Cough  is  a  constant  symptom.  It  is  generally  most 
troublesome  at  night,  and  a  prolonged  coughing  spell  is  usually  in- 
duced by  the  accumulation  of  mucus  after  a  few  hours'  sleep.  Dyspnea 
is  generally  a  prominent  feature,  occurring  especially  upon  exertion,  as 
in  climbing  a  hill  or  ascending  a  flight  of  stairs.  It  is  due  either  to 
deficient  aeration  of  the  blood  or  to  cardiac  weakness.  A  sense  of  op- 
pression or  of  soreness  in  the  chest  is  usually  complained  of,  which 
appears  to  be  due  either  to  the  strain  of  coughing  or  to  the  exaggerated 
action  of  the  respiratory  muscles.  Acute  pain  is  unusual.  All  the  symp- 
toms are  subject  to  frequent  changes.  Inclement  weather,  change  of 
temperature,  and  exposure  produce  exacerbations.  The  disease  is  always 
worse  in  winter.  For  a  number  of  years  it  may  almost  wholly  subside 
during  the  summer,  but  each  year  the  period  of  relief  becomes  shorter 
until  the  cough  and  expectoration  become  constant.  Evening  elevation 
of  temperature  is  frequently  observed,  especially  during  the  more  severe 
periods  of  the  disease ;  but  in  many  cases  it  is  so  slight  as  to  be  over- 
looked. The  sputum  is  variable,  changing  from  time  to  time.  Some- 
times it  consists  of  thick,  tenacious  mucus,  sometimes  of  almost  pure 
pus;  in  some  cases  it  is  always  thin  and  fluid  or  frothy.  Cases  of  "dry 
catarrh"  occur  also,  in  which  there  is  little  or  no  expectoration.  These 
and  other  differences  in  the  character  of  the  sputum  have  led  to  the 
recognition  of  four  forms  of  chronic  bronchitis  :  («)  The  common  form, 
which  has  just  been  described,  (^)  bronchorrhea,  (r)  putrid  bronchitis, 
and  ((/)  dry  bronchitis. 

Bronchorrhea. — This  name  is  applied  to  cases  in  which  the  bronchial 
secretion  is  excessive  in  quantity.  The  sputum  is  generally  purulent, 
rather  thin  and  greenish;  sometimes  it  is  almost  serous  in  character, 
but,  on  the  other  hand,  it  may  be  tenacious.  The  entire  bronchial 
mucous  membrane  is  usually  affected.  Although  the  condition  is  not 
one  of  bronchiectasis,  it  is  apt  to  lead  to  dilatation  of  the  bronchi, 
and  the  accumulation  of  secretion  may  cause  the  development  of  a 
putrid  bronchitis. 

Fetid  or  Putrid  Bronchitis.— This  is  characterized  by  an  abundant 
expectoration  of  fetid,  mucopurulent,  heavy  greenish,  or  thin  grayish 
sputum  mixed  with  frothy  mucus,  which  separates  on  standing  into 
three  layers,  the  upper  consisting  of  the  frothy  mucus,  the  middle  of 
clear  serum,  and  the  lower  of  thick  purulent  matter  often  containing 
the  so-called  Dittrich's  plugs,  firm  yellow  masses  as  big  as  peas,  composed 
of  granular  matter,   fat-globules,   and  fatty  acids,  with  putrid  animal 


BRONCHITIS      .  391 

matter  and  sometimes  fungi.  Fever  is  more  constant  in  this  form 
than  in  simple  bronchitis.  This  form,  too,  is  often  associated  with 
bronchiectasis,  gangrene  or  abscess  of  the  lung,  or  advanced  tuberculosis. 

Dry  catarrh,  as  already  stated,  is  characterized  by  a  more  or  less 
complete  absence  of  expectoration.  It  is  generally  associated  with  em- 
physema in  old  persons. 

Physical  Signs. — The  physical  signs  are  nearly  the  same  as  those 
of  acute  bronchitis.  The  resonance  on  percussion  is  slightly  tympanitic. 
Sonorous  and  sibilant  rales  are  heard,  and  mucous  rales  of  every  variety 
are  always  present,  and  generally  in  all  regions  of  the  lungs.  An  occa- 
sional extension  of  the  catarrh  to  the  smaller  tubes  is  common,  during 
which  times  subcrepitant  rales  can  be  heard  at  the  base  and  margins 
of  the  lungs. 

Treatment. — Prophylaxis  is  of  the  greatest  value.  The  patient  should, 
if  possible,  make  such  changes  of  occupation  or  residence  as  will  enable 
him  to  avoid  the  inciting  causes  of  the  disease.  The  climate  in  this 
country  best  suited  to  the  condition  is  found  in  southern  California, 
at  San  Diego,  or,  better,  in  the  villages  in  the  foot-hills  of  the  mountains 
near  that  city  or  Los  Angeles.  The  southern  part  of  Florida  is  suitable 
for  a  winter's  sojourn.  Next  in  importance  is  the  constitutional  con- 
dition of  the  patient.  If  there  be  an  arthritic  diathesis,  heart  or  kid- 
ney disease,  these  should  receive  attention.  If  the  patient  be  tuberculous, 
the  treatment  of  that  condition  overshadows  that  of  the  bronchial 
affection.  The  digestion  must  be  regulated  with  especial  reference  to 
the  prevention  of  flatulency,  a  most  distressing  condition  to  the  patient. 
The  clothing  should  be  warm,  but  modified  to  suit  changes  of  tempera- 
ture. All  exposure  must  be  avoided,  particularly  the  respiration  of 
cold  air.  While  the  patient  should  take  moderate  exercise,  he  should 
avoid  overexertion  and  hard  work. 

The  medicinal  treatment  must  be  suited  to  the  case.  Potassium  iodid 
or  the  sirup  of  the  iodid  of  iron  is  more  generally  beneficial  than  any 
other  remedy,  particularly  when  the  secretion  is  scant.  When  the  secre- 
tion is  free,  the  fluid  extract  of  senega  may  be  added  to  the  solution. 
Atropin  is  sometimes  of  service  in  bronchorrhea.  Among  other  remedies 
generally  used  are  ammonium  chlorid,  sodium  benzoate,  and  other  alkalis, 
ipecacuanha,  tolu,  tar,  creosot,  sandalwood,  resin  of  copaiba,  compound 
tincture  of  benzoin,  and  terebene.  Inhalations  of  the  vapor  of  turpentine, 
benzoin,  creosot,  eucalyptus,  or  a  spray  containing  one  of  these  or  the 
wine  of  ipecacuanha  are  all  recommended.  In  fetid  bronchitis,  a  spray 
containing  carbolic  acid  (2  per  cent)  should  be  used  to  destroy  the 
odor. 

FIBRINOUS  BRONCHITIS. 

CROUPOUS,   EXUDATIVE,   PLASTIC,   OR  PSEUDOMEMBRANOUS   BRONCHITIS. 

Definition. — An  acute  or  chronic  inflammatory  affection  of  the  bron- 
chial mucous  membrane  characterized  by  a  deposit  of  plastic  matter 
which  becomes  detached  and  is  expectorated  in  the  form  of  a  more  or 
less  extensive  cast  of  the  bronchial  tree.  A  distinction  must  be  made 
between  true  fibrinous  bronchitis,  a  comparatively  rare  disease,  and  those 
conditions  in  which  the  expectoration  of  similar  molds  results  from  an 


392 


PRACTICE  OF  MEDICINE 


accumulation  of  clotted  blood  in  hemoptysis,  an  extension  of  the  diph- 
theritic membrane,  or  of  the  fibrinous  exudate  in  acute  pneumonia. 

Etiology.  —  No  specific  cause  is  known,  but  it  is  probably  not  the 
same  in  all  cases.  The  disease  is  more  common  in  Europe  than  in  this 
country  and  usually  occurs  during  the  late  springtime.  It  is  not  limited 
to  any  period  of  life,  but  is  rare  under  the  tenth  or  after  the  fortieth 
year.  It  is  twice  as  frequent  in  men  as  in  women.  The  patient  is  gen- 
erally in  an  anemic,  debilitated  condition  when  attacked,  as  a  result  of 
such  diseases  as  measles,  scarlet  fever,  pneumonia,  or  typhoid  fever, 
and  many  are  tuberculous  or  syphilitic.  Its  occurrence  in  pregnancy, 
and  its  association  with  such  cutaneous  affections  as  herpes  and  pemphi- 
gus, have  been  repeatedly  noted.  Various  bacteria  have  been  found  in 
the  secretions,  but  none  has  been  identified  with  the  disease. 

Morbid  Anatomy. — The  bronchial  mucous  membrane  has  "been  found 
hyperemic,    the    epithelium  sometimes  intact,   sometimes  desquamated. 

The  inflammation  is  more 
general  in  the  acute  form 
than  in  the  chronic.  The 
casts  (Fig.  23),  pure  white 
or  cream,  color,  sometimes 
streaked  with  blood,  are 
firm  and  elastic  and  cor- 
respond in  size  to  the 
lumen  of  the  part  of  the 
bronchial  tree  in  which 
they  originate.  They  are 
probably  composed  of  mu- 
cin, although  they  have 
been  generally  regarded  as 
fibrinous. 

Symptoms. — The  acute 
form  may  have  a  sudden, 
severe  onset,  with  high  fe- 
ver, chill,  dry  cough,  dysp- 
nea, and  constriction  of 
the  chest,  but  in  most  cases  it  begins  as  a  simple  acute  bronchitis,  with 
cough,  scant  expectoration  of  clear  mucus,  and  possibly  a  slight  elevation 
of  temperature.  In  children  it  is  often  preceded  by  malaise.  Much  differ- 
ence has  been  noted  in  the  severity  and  abruptness  of  the  initial  symp- 
toms in  different  cases.  A  chill  may  mark  the  transition  from  the 
simple  to  the  fibrinous  form.  The  pulse-rate  is  accelerated,  and,  with 
the  development  of  casts,  the  cough  becomes  more  harassing  and  parox- 
ysmal and  the  dyspnea  more  pronounced.  Slight  hemorrhage  sometimes 
accompanies  or  follows  their  expulsion.  Relief  follows  the  removal  of 
the  obstruction,  but  it  is  transitory,  and  the  paroxysm  may  recur  within 
a  few  hours.  In  severe  cases,  digestion  becomes  impaired,  nutrition  is 
interfered  with,  and  great  nervous  irritability  may  be  exhibited.  Re- 
covery takes  place  by  a  gradual  subsidence  of  the  symptoms ;  the  casts 
no  longer  appear,  the  temperature,  although  high,  rapidly  declines, 
appetite  and  strength  return.  Fatal  cases  generally  terminate  in  from 
three  days  to  two  weeks,  sometimes  suddenly  by  suffocation. 


Fig.  23. — Casts  from  a  case  of  fibrinous  bronchi- 
tis.    (2-5  natural  size.) 


Practice  of  Medicine.— French. 


PLATE  X. 


Bronchiectasis  with  Chronic  Tuberculosis. 

The  ragged  communicating  cavities  involve  a  large  part  of  the  lung  and  are  bron- 
chiectatic  in  origin.  The  bronchial  lymph -nodes  are  enlarged,  tuberculous,  and  caseous. 
The  pleura  and  interlobar  septum  are  thickened  by  the  formation  of  dense  fibrous  tissue. 


{^By permission,  frotn  " Delqfigld and  Prudden.") 


BRONCHIECTASIS  393 

The  chronic  form  generally  follows  a  more  or  less  protracted  bronchial 
catarrh.  Its  course  is  one  of  exacerbations  and  remissions.  Paroxysms 
of  cough,  dyspnea,  and  constriction  occur,  to  be  followed  by  temporary 
relief  when  the  casts  are  expelled,  but  they  recur  at  longer  or  shorter 
intervals  for  weeks,  months,  or  years.  Every  grade  of  severity  is  seen 
in  the  recurrences,  and  months  or  years  of  perfect  health  may  intervene. 
The  temperature  rises,  if  at  all,  during  the  exacerbations  and  does  not 
generally  reach  so  high  a  degree  as  it  does  in  the  acute  form. 

The  physical  signs  are  variable  and  depend  upon  the  presence  or  ab- 
sence of  casts  at  the  time  of  examination.  In  acute  cases  there  may 
be  all  the  evidences  of  an  acute  bronchitis;  in  the  intervals  of  quiescence 
there  may  be  no  adventitious  signs.  The  casts  are  readily  recognized 
when  the  sputum  is  deposited  in  water,  where  they  unfold. 

Treatment — It  is  difficult  to  estimate  the  results  of  treatment,  since 
so  few  cases  have  come  under  the  care  of  any  one  observer.  Potassium 
iodid  has  been  employed  more  than  any  other  remedy,  but  its  effects 
have  not  been  uniformly  satisfactory.  Ammonium  chlorid,  ipecacuanha, 
senega,  benzoic  acid,  apomorphin,  and  other  expectorants  have  been 
recommended.  Emetics  may  be  employed  in  robust  individuals  to  assist 
in  the  expulsion  of  the  casts  after  they  have  become  detached.  Creosot 
carbonate  in  15-drop  doses  is  worthy  of  a  trial. 

Obliterative  Bronchitis. — Under  the  term  bronchitis  obliterans  Lange 
and  A.  Frankel  have  reported  three  cases  in  which  a  plastic  exudate 
in  the  bronchi,  instead  of  becoming  detached,  underwent  organization 
and  caused  a  fatal  obliteration  of  the  air-spaces  in  a  considerable  por- 
tion of  both  lungs.  The  disease  followed  the  inhalation  of  highly  irritat- 
ing fumes. 

BRONCHIECTASIS. 

Definition. — A  general  or  localized  dilatation  of  the  bronchial  tubes. 

Etiology. — The  disease  is  more  common  in  middle  life,  but  it  has  been 
found  as  a  congenital  condition ;  men  are  more  frequently  affected  than 
women.  The  direct  cause  is  believed  to  be  a  weakness  of  the  walls  induced 
by  inflammation  involving  the  muscle,  fibrous,  and  cartilaginous  struc- 
tures, aided  by  the  weight  of  accumulated  secretions  and  probably  by  the 
expansive  force  of  coughing.  The  disease  is  generally  secondary  to  :  («) 
Chronic  bronchitis  and  emphysema,  (i^)  interstitial  pneumonia,  broncho- 
pneumonia, or  tuberculosis,  (^)  compression  of  the  bronchi  by  solid 
tumors  or  aneurism,  (^)  impaction  of  a  foreign  body,  or  (<?)  contraction 
of  the  lung  caused  by  thickening  of  the  pleura.  An  acute  form  of  the 
disease  has  been  observed  in  children;  in  adults  it  is  generally  chronic. 

Morbid  Anatomy. — The  dilatation  may  be  single  or  multiple  and  thecav- 
ities  may  be  fusiform  or  saccular ;  they  vary  in  diameter  from  a  half-inch 
to  three  or  four  inches.  (See  Plate  X.)  They  may  be  found  in  any  part 
of  the  lungs.  The  wall  of  the  cavity  is  usually  thin;  sometimes  it  is  lined 
by  a  thick,  indurated  membrane,  often  ulcerated ;  sometimes  the  epithelium 
remains  more  or  less  intact.  Perforation  sometimes  occurs.  The  content 
of  the  cavity  is  a  thick,  greenish  or  brown,  fetid,  mucopurulent  matter. 

Symptoms. — The  symptoms  are  the  same  as  those  of  chronic  fetid 
bronchitis,  and  the  disease  cannot  always  be  distinguished  during 
life.    In  the  more  advanced  cases,  however,  the  condition  can  generally 


394  PRACTICE  OF  MEDICINE 

be  recognized  through  the  character  of  the  cough  and  expectoration. 
The  cough  is  paroxysmal,  usually  worse  in  the  morning  or  after  rising 
from  a  recumbent  posture.  An  enormous  quantity  of  sputum  is  brought 
up,  sometimes  amounting  to  more  than  a  pint  in  24  hours.  After  the 
paroxysm  the  patient  may  pass  the  greater  part  of  the  day  without 
cough  or  expectoration.  The  sputum  is  generally  rather  thin,  gray  or 
brownish,  and  purulent,  with  a  sour  or  fetid  odor.  It  separates,  on 
standing,  into  three  layers  similar  to  those  of  the  sputum  in  fetid  bron- 
chitis. Microscopic  examination  reveals  pus-cells,  crystals  of  fatty  acids, 
often  arranged  in  bundles,  sometimes  hematoidin  crystals,  various 
bacteria,  and,  when  there  is  extensive  ulceration,  elastic  fibers.  Dyspnea 
is  not  always  a  prominent  symptom.  Hemorrhage,  generally  slight, 
occurs  in  nearly  half  the  cases.  In  cases  of  long  standing  the  patient 
often  becomes  cyanotic  after  exertion,  his  finger-ends  become  clubbed 
and  the  nails  incurved. 

The  physical  signs  depend  largely  upon  the  extent  of  the  bronchial 
dilatation.  Retraction  of  the  chest-wall  has  been  noted,  but  it  is  due  to 
the  contraction  of  the  lung  caused  by  chronic  pleurisy  or  interstitial 
pneumonia  in  most  cases.  The  percussion  note  may  be  tympanitic  over 
superficial  cavities,  and  amphoric  breathing  may  be  heard,  especially 
at  the  base  of  the  lungs. 

Diagnosis. — The  disease  cannot  always  be  differentiated  from  chronic 
bronchitis  until  the  cavity-formation  has  reached  a  stage  that  yields 
characteristic  physical  signs.  From  tuberculosis  it  is  distinguished  by 
its  prolonged  course  and  the  absence  of  the  tubercle  bacillus.  A  saccu- 
lated empyema  having  a  fistulous  communication  with  a  bronchus  is 
distinguished  with  difficulty,  but  the  evacuation  of  the  cavity  is  not 
usually  so  frequent.  Cancerous  ulceration  of  the  lung  and  gangrene 
need  seldom  be  considered,  owing  to  the  rapidity  of  their  progress. 
Actinomycosis  of  the  lung  has  been  mentioned  in  this  connection,  but 
it  is  rare  and  can  be  recognized  by  the  discovery  of  the  fungus. 

Prognosis. — The  disease  usually  persists  for  many  years,  ultimately 
tending  to  a  fatal  termination,  but  cases  of  supposed  recovery  have 
been  reported. 

Treatment. — Little  is  to  be  anticipated  from  internal  medication. 
Creosot  in  increasing  doses,  quinin,  salol,  and  turpentine  have  been  em- 
ployed. Terebene,  TT|,v  to  x  (0.33 — 0.66)  every  four  hours,  has  proved 
beneficial  in  some  cases.  Better  results  are  obtained,  however,  from  the 
inhalation  of  sprays  of  antiseptic  substances — eucalyptus,  thymol,  ben- 
zoin, creosot,  or  carbolic  acid.  The  most  satisfactory  method  of  treat- 
ment, in  many  cases,  is  the  intratracheal  injection  of  a  solution  of 
menthol  10  parts,  guaiacol  2  parts,  in  olive  oil  88  parts.  Of  this  a 
dram  (3.6)  is  injected  twice  a  day  with  a  special  syringe,  which  renders 
the  use  of  a  laryngoscope  unnecessary.  Inhalations  of  vaporized  creosot 
have  also  been  found  of  great  benefit. 

BRONCHIAL  ASTHMA. 

SPASMODIC  ASTHMA. 

Definition.— A.  form  of  dyspnea  due  to  temporary  alteration  of  the 
condition  of  the  smaller  bronchial  tubes.    The  term  asthma    is    often 


BRONCHIAL  ASTHMA  395 

applied  also  to  the  dyspnea,  more  or  less  spasmodic  in  character,  which 
arises  from  cardiac  or  renal  disease  (cardiac  or  renal  asthma). 

Etiology. — There  are  four  leading  theories  of  the  nature  and  cause 
of  asthma,  natnely,  that  it  is  due  :  ( i )  To  a  spasm  of  the  bronchial 
muscles,  and  probably  a  neurosis;  (2)  to  a  swelling  of  the  bronchial 
mucous  membrane  caused  by  hyperemia,  vasomotor  nervous  influence, 
or  the  presence  of  a  toxic  irritant  in  the  blood;  (3)  to  an  inflammation 
of  the  bronchioles,  a  bronchiolitis  exudativa  (Curschmann) ;  and  (4) 
that  it  is  due  to  a  reflex  spasm  of  the  diaphragm,  probably  involving 
also  the  other  respiratory  muscles. 

The  disease  is  met  with  in  persons  of  any  age,  from  early  infancy 
to  extreme  old  age,  but  it  commonly  begins  in  early  life.  It  is  more 
frequent  in  men.  There  is  great  difference  in  individual  susceptibility., 
Many  patients  are  to  be  regarded  as  neurotic;  there  is  at  least  a  nerv- 
ous temperament,  an  instability  of  the  nervous  system.  The  disease 
has  been  known  to  alternate  with  epilepsy,  and  is  often  accompanied 
by  neuralgia  and  other  nervous  affections.  The  hereditary  transmission 
is  often  distinct.  It  is  closely  allied  to  hay  fever.  It  is  to  a  great 
extent  a  disease  of  the  better  classes.  It  often  follows  whooping-cough 
or  other  acute  infectious  disease,  and  in  many  cases  it  is  associated 
with  disease  of  the  upper  respiratory  passages,  particularly  with  hyper- 
trophic rhinitis  or  polyp  of  the  nose.  The  exciting  causes  are  of  the 
greatest  variety  and  they  are  generally  peculiar  to  the  individual.  Asth- 
matics living  in  the  city  are  free  from  it  in  the  country;  those  residing 
on  the  hill  are  relieved  by  descending  into  the  valley,  and  vice  versa. 
The  attack  is  often  induced  in  one  person  by  an  odor  which  does  not 
affect  another,  as  by  that  of  a  certain  flower  or  of  a  certain  animal, 
of  feathers  or  of  ipecacuanha.  Dust,  smoke,  and  irritating  vapors  often 
induce  an  attack.  Nervous  impression  or  emotion,  particularly  fright, 
may  cause  it,  and  sometimes  it  appears  to  depend  upon  a  disturbance 
in  some  other  organ,  especially  the  stomach,  intestines,  or  genitals. 
A  contraction  of  the  bronchial  tubes  has  been  induced  experimentally 
by  electric  stimulation  of  the  vagus. 

Morbid  Anatomy. — The  disease  has  no  anatomical  lesions  peculiar  to 
itself,  but  it  is  usually  associated  with  those  of  chronic  bronchitis  and 
emphysema. 

Symptoms. — The  attack  may  come  on  suddenly  in  the  midst  of  the 
night,  or  there  may  be  such  premonitory  symptoms  as  chilliness,  a  feel- 
ing of  oppression  in  the  chest,  depression  of  spirits,  indigestion,  or 
some  nervous  manifestations.  The  patient  is  unable  to  lie  down;  he 
often  sits  at  an  open  window  or  seeks  the  open  air.  Some  patients  are 
always  able  to  predict  an  attack;  others  can  rarely  do  so.  The  onset 
may  be  gradual  or  sudden,  with  a  constantly  increasing  sense  of  oppres- 
sion, deepening  into  the  most  intense  dyspnea.  The  respiratory  efforts 
become  violent.  All  the  accessory  muscles  are  called  into  action,  but 
only  a  comparatively  small  volume  of  air  enters  the  lungs,  and  the 
expiration  is  equally  difficult  and  much  prolonged.  It  is  usually  ac- 
companied with  wheezing.  The  face  becomes  pale,  sometimes  livid,  the 
expression  is  anxious.  Speech  is  impossible.  If  the  paroxysm  continue, 
the  deficient  oxygenation  of  the  blood  becomes  more  apparent;  the 
face  becomes  cyanotic  and  moist,  the  extremities  become  cold,  and,  to  the 


396  PRACTICE    OF  MEDICINE 

inexperienced,  death  seems  imminent;  but,  with  the  deepening  of  the  cya- 
nosis and  the  approach  of  unconsciousness,  the  spasm  relaxes  and  the 
breathing  becomes  less  labored.  The  paroxysm  often  terminates  with  a 
fit  of  coughing  and  the  expectoration  of  a  considerable  quantity  of 
mucus.  The  attack  lasts  from  a  few  minutes  to  several  hours,  sometimes 
even  days,  with,  perhaps,  short  intermissions.  The  relief  is  not  usually 
complete ;  the  breathing  is  still  laborious,  and  very  often  the  paroxysm 
is  repeated  within  a  few  hours.  During  the  attack,  clear,  pale  urine  of 
low  specific  gravity  is  often  voided  at  short  intervals  and  in  large  quan- 
tity. The  sputum  is  characteristic.  At  first  brought  up  with  difficulty, 
it  becomes  more  abundant,  and  in  the  masses  of  clear  mucus  can  be 
seen  small,  round,  gelatinous  bodies,  the  perles  of  Laennec,  which,  when 
floated  in  water  and  examined  with  a  lens,  are  found  to  be  formed  of 
spirally  arranged  mucin  casts  of  the  smaller  bronchial  tubes.  They  are 
known  also  as  the  Curschmann  spirals.  Examined  with  a  higher  power, 
some  of  these  are  seen  to  contain,  in  the  center,  a  thread  of  clear  mucin, 
while  others  are  merely  twisted  casts.  Numerous  leucocytes,  mostly 
eosinophiles,  are  usually  entangled  in  them,  and  Charcot-Leyden  crystals, 
octahedra  of  ethylenimin  phosphate,  are  generally  present.  In  the  course 
of  a  few  days  the  sputum  becomes  mucopurulent,  and  the  spirals  can 
no  longer  be  found  in  it.  The  eosinophiles  are  greatly  increased  in  the 
blood. 

The  physical  signs  of  asthma  are  diagnostic.  The  thorax  is  fixed, 
and  the  respiratory  excursions  are  exceedingly  limited.  The  inspiration 
is  quick  and  jerking,  while  the  expiration  is  prolonged  to  more  than 
double  its  normal  duration.  On  percussion,  the  resonance  is  increased 
(/.  (?.,  tympanitic),  especially  when  emphysema  is  present.  Auscultation 
reveals  dry,  sibilant  and  sonorous,  whistling  rales  on  expiration.  The 
vesicular  murmur  is  entirely  suppressed,  or  it  is  replaced  by  bronchial 
breathing. 

Prognosis. — Asthma  is  not  fatal  and  may  last  for  a  lifetime.  The 
paroxysms  never  terminate  fatally.  Bronchopneumonia  may,  however, 
supervene. 

Treatment. — The  remedies  for  the  paroxysm  are  many  and,  for  the 
most  part,  effective  in  certain  cases,  but  not  in  all.  The  simplest  of 
them  consist  in  the  inhalation  of  the  fumes  of  burning  niter-paper, 
stramonium  leaves,  tobacco,  or  cigarettes  containing  one  or  more  of 
these  substances;  or  inhalation  of  chloroform,  ether,  or  amyl-nitrite. 
The  internal  administration  of  chloral  or  caff'ein,  and  the  hypodermic 
administration  of  morphin,  are  promptly  effective,  but  such  remedies, 
with  the  exception  of  caff'ein,  should  be  used  cautiously  on  account  of 
the  danger  of  producing  a  habit.  A  cup  of  hot  coffee  or  a  hot  toddy 
will  arrest  the  attack  in  some  individuals.  Inhalations  of  oxygen  help 
some  patients,  but  not  others.  The  pneumatic  cabinet  has  been  of 
benefit  in  some  cases,  under  an  increased  pressure  of  from  a  half  to  one 
atmosphere. 

During  the  interval,  potassium  iodid  in  doses  of  gr.  v  to  xx  (0.30 — 
1.2)  three  times  a  day  has  proved  the  most  effective  remedy  in  most 
cases,  often  completely  arresting  the  disease  for  a  considerable  length  of 
time.  The  diet  should  be  regulated  with  particular  care  as  to  the  quan- 
tity>  of  food  taken  in  the  evening.    The  patient  should  dine  at  noon, 


HYPEREMIA 


397 


eat  a  light  supper,  and  should  never  eat  late  at  night.  The  quantity 
of  carbohydrates  should  be  limited,  especially  at  the  evening  meal. 
But  many  articles  which  agree  with  one  patient  cause  great  disturbance 
in  another.  Climate  exerts  a  beneficial  influence,  but  in  this  respect 
also  patients  diff'er.  Some  do  well  in  the  higher  altitudes,  but  most  of 
them,  and  particularly  those  having  emphysema,  generally  do  better 
near  the  seacoast,  in  an  equable  climate,  like  that  of  southern  Cali- 
fornia or  Florida. 

DISEASES    OF   THE    LUNGS. 
HYPEREMIA. 

Hyperemia,  or  congestion,  of  the  lungs  may  be  either  active  or  pas- 
sive. Both  the  parenchyma  of  the  lungs  and  mucous  membrane  of  the 
bronchial  tubes  are  generally  involved. 

I.  Active  Hyperemia.— £f/o/o5'/.— Some  writers  go  so  far  as  to  doubt 
the  occurrence  of  primary  active  hyperemia  of  the  lung.  There  can 
be  little  doubt,  however,  that  it  sometimes  occurs:  (i)  As  a  result  of 
the  inhalation  of  hot  air,  illuminating  gas,  or  irritant  vapors,  and 
(2)  sometimes  in  individuals  whose  occupation  requires  them  to  enter 
cold-storage  vaults  while  actively  working.  (3)  It  is  generally  supposed 
to  develop  in  one  portion  of  the  lung  when  the  circulation  of  another 
part  is  interfered  with;  and  it  occurs  (4)  in  the  beginning  of  such  pul- 
monary diseases  as  bronchitis,  pneumonia,  pleurisy,  and  tuberculosis. 
(5)  It  occasionally  results  from  violent  fits  of  coughing,  (6)  from  too 
great  atmospheric  pressure,  like  that  encountered  by  deep-sea  divers 
and  workers  in  caissons,  or  (7)  from  violent  action  of  the  heart,  as 
that  occasioned  by  athletic  sports  or  cycling. 

Symptoms. — The  development  of  an  active  hyperemia  is  generally  an- 
nounced by  a  chill  immediately  or  a  few  hours  after  its  onset,  with  pain 
in  the  side,  dyspnea,  a  dry  cough,  and  moderate  elevation  of  tempera- 
ture (101° — 103°  F. ;  38.3° — 39.5°  C).  Examination  reveals  diminished 
resonance,  feeble  or  bronchial  breathing,  subcrepitant  rales,  sometimes 
over  the  entire  afi'ected  lung.  Death  has  resulted  from  the  condition 
within  the  first  24  hours,  but  in  most  cases  complete  recovery  occurs.^ 

Passive  Hyperemia. — This  form  of  congestion  is  of  two  kinds,  mechan- 
ical and  hypostatic. 

(«)  Mechanical  hyperemia  or  congestion  is  caused  almost  exclusively 
by  valvular  lesions  or  dilatation  and  weakness  of  the  heart  which  inter- 
feres with  the  normal  return  of  blood  from  the  lungs.  It  is  sometimes 
induced,  however,  by  the  pressure  of  aneurisms  or  other  tumors.  The 
condition  produced  in  the  lung  is  known  as  brown  induration.  The 
lung  becomes  distended  with  blood,  its  tissues  indurated  and  of  a  brown- 
ish red  color.  On  microscopic  examination  the  capillary  vessels  are  found 
to  be  distended,  the  connective  tissue  is  hyperplastic,  and  the  alveoli 
contain  many  desquamated  epithelial  cells  in  various  stages  of  degenera- 
tion and  pigmentation. 

Symotoms. — The  condition,  when  well  marked,  is  indicated  by  dysp- 
nea and  the  expectoration  of  sputum  containing  degenerated  and  pig- 
mented alveolar  cells  and  possibly  free  blood,  in  quantity  sufficient  to  be 


398  PRACTICE  OF  MEDICINE 

evident.  Dullness  may  be  found  on  percussion,  and  moist  rales  on  auscul- 
tation. 

((^)  Hypostatic  Congestion. — This  condition  is  caused  by  weakness  of 
the  heart's  action  and  favored,  in  some  cases  largely  induced,  by  gravi- 
tation of  the  blood  to  the  most  dependent  portion  of  the  lung  as  a 
result  of  too  prolonged  lying  in  the  same  posture.  It  is  most  frequently 
encountered,  therefore,  in  the  continued  fevers,  notably  in  typhoid,  and 
more  chronic  diseases.  The  posterior  parts  of  the  lungs  are  engorged 
with  blood  and  become  dark,  often  almost  black.  The  affected  portion 
of  the  lung  may  contain  so  little  air  that  it  will  sink  in  water.  This 
condition  is  often  referred  to  as  splenization.  A  form  of  hypostatic 
congestion,  usually  less  pronounced  than  the  foregoing,  is  met  with  in 
some  cases  of  cerebral  hemorrhage,  especially  in  aged  persons  or  as  a 
result  of  cerebral  tumors  situated  near  the  respiratory  center,  and  some- 
times in  cases  of  uremic  coma  or  opium-poisoning. 

Symptoms. — The  condition  is  recognized  by  dullness  on  percussion, 
the  absence  of  the  vesicular  murmur,  and  the  presence  of  moist  rales, 
moderate  dyspnea  and  cough,  sometimes  accompanied  with  blood-stained 
expectoration,  under  conditions  favorable  to  its  development.  The  con- 
gestion can  be  made  to  clear  up  on  the  affected  side  by  changing  the 
position  of  the  patient. 

Treatment. — In  active  congestion,  great  relief  may  be  afforded  by 
a  hot  bath,  by  the  application  of  wet  or  dry  cups,  a  poultice,  or  mus- 
tard over  the  affected  area.  In  extreme  cases,  general  blood-letting  is 
more  certain  and  prompt.  Aspiration  of  the  right  auricle  has  been  ad- 
vised, if  the  blood  does  not  flow  freely  from  the  arm.  If  blood-letting 
cannot  be  resorted  to,  the  tincture  of  aconite  in  doses  of  a  half  to  one 
drop  every  15  minutes  for  an  hour  or  two  may  be  given  for  its  action 
on  the  heart. 

In  passive  congestion  the  chief  indication  is  the  treatment  of  the 
cause.  Remedies  should  be  applied  to  strengthen  the  heart's  action  and, 
if  possible,  to  overcome  the  dilatation.  Hypostatic  congestion  should  be 
treated  prophylactically.  It  should  be  prevented  by  proper  attention 
to  the  posture  of  the  patient.  When  it  has  developed,  it  may  be  removed 
by  changing  the  posture,  and  by  careful  stimulation  of  the  circulation, 
preferably  with  strychnin. 

EDEMA  OF  THE  LUNGS. 

Definition. — A  transudation  of  serum  into  the  air-cells  and  alveolar 
walls  of  the  lungs. 

Etiology.— The  most  prominent  cause  of  transudation  is  hyperemia, 
particularly  passive  hyperemia.  The  causes  of  edema  are,  therefore, 
practically  the  same  as  those  of  passive  congestion,  and  the  most  im- 
portant of  them  is  a  feeble  action  of  the  heart  due  to  dilatation,  degen- 
eration, or  chronic  pericarditis.  Edema  occurs  also  in  connection  with 
chronic  nephritis,  hepatic  cirrhosis,  profound  anemia,  cachexias,  or  any 
condition  in  which  there  is  a  hydremic  condition  of  the  blood;  in  some 
cerebral  affections  and  in  some  cases  of  acute  ascending  spinal  paralysis. 
In  all  such  conditions  it  is  often  a  terminal  affection,  frequently  occur- 
ring during  the  death  struggle,  a   final  relaxation  of  the  blood-vessel 


PULMONARY  HEMORRHAGE  399 

walls  that  permits  the  escape  of  serum.  A  so-called  collateral  edema 
occurs  in  the  neighborhood  of  inflammatory  processes,  infarcts,  new 
growths,  and  tubercular  formations.  An  acute  angioneurotic  edema 
is  also  believed  to  occur,  similar  to  that  which  affects  the  larynx  and 
various  other  parts  of  the  body.  It  comes  on  suddenly,  often  in  an 
individual  apparently  in  good  health,  except,  perhaps,  for  a  slight  gastric 
disturbance,  with  attacks  of  gastralgia  and  vomiting.  The  cause  is 
supposed  to  be  some  irritant  in  the  blood,  probably  an  unoxidizable 
product  of  digestion  which  causes  vasomotor  paralysis  and  consequent 
dilatation  of  blood-vessels  and  transudation. 

Morbid  Anatomy. — ^Vhen  the  edema  is  great,  the  lung  may  have  a 
gelatinous  appearance;  it  is  heavy,  pits  on  pressure,  and,  when  incised, 
discharges  a  large  quantity  of  serum,  which  is  blood-stained  when  the 
condition  accompanies  congestion.  The  edema  may  be  general,  but  it 
is  usually  most  marked  at  the  base  and  dependent  portions  of  the  lungs. 

Symptoms. — The  symptoms  are  rapid  breathing,  audible  bubbling 
or  rattling,  and  dyspnea.  There  is  the  same  sense  of  oppression  as  in 
asthma.  The  patient  cannot  lie  down.  All  the  respiratory  muscles 
assist.  The  expectoration  consists  of  an  abundance  of  watery,  frothy, 
blood-stained  serum.  Cyanosis  often  becomes  extreme.  Edema  is  usually 
present  in  other  parts  of  the  body,  and  the  condition  may  be  a  part, 
usually  the  termination,  of  a  general  dropsy.  The  percussion  note  is 
dull,  especially  over  the  dependent  portions  of  the  lungs,  and  fine  moist 
rales  are  exceedingly  numerous  in  all  parts  of  the  chest.  In  secondary 
edema  the  temperature  is  sometimes  subnormal,  especially  when  it  is 
the  result  of  chronic  nephritis,  but  in  the  so-called  inflammatory  edema 
there  is  always  fever,  and  the  condition  closely  resembles  one  of  pneu- 
monia. 

Prognosis. — This  is  always  grave,  for  the  edema  often  proves  rapidly 
fatal,  sometimes  within  an  hour.  But  in  chronic  cases  several  attacks 
of  moderate  severity  are  sometimes  recovered  from.  The  circumscribed, 
inflammatory  edema  is  less  dangerous. 

Treatment. — A  severe  attack  of  pulmonary  edema  calls  for  prompt 
treatment.  If  there  is  much  cyanosis  and  the  condition  of  the  patient 
will  permit,  free  venesection  affords  the  quickest  relief.  Dry  cups  may 
be  applied  freely  over  all  parts  of  the  chest,  thirty  or  more  at  a  single 
application.  The  object  is  not  to  draw  blood,  but  to  stimulate  absorp- 
tion. In  some  cases  the  patient  is  benefited  by  very  hot  fomentations, 
turpentine  stupes,  a  poultice,  or  mustard  applied  to  the  chest.  The 
inhalation  of  oxygen  may  assist  in  tiding  the  patient  over.  Strychnin 
should  be  given  hypodermically,  gr.  1-40  (0.0016),  if  the  heart's  action 
is  feeble.  Nitroglyerin  (gr.  1-50;  0.0013)  assists  in  equalizing  the  cir- 
culation, and  a  free  purge  should  be  given  to  aid  absorption. 

PULMONARY  HEMORRHAGE. 

Two  very  different  conditions  are  described  under  this  head ;  broncho- 
pulmonary hemorrhage  or  bronchorrhagia,  and  pulmonary  apoplexy 
or  hemorrhagic  infarct,  sometimes  referred  to  as  pneumorrhagia. 

I.  Bronchopulmonary  hemorrhage  is  the  form  that  is  usually  desig- 
nated by  the  term  hemoptysis,  or  the  spitting  of  blood.     Although  some 


40  o  PRACTICE  OF  MEDICINE 

writers  include  in  this  class  of  cases  hemorrhages  from  the  upper  respira- 
tory passages,  the  term  is  generally  understood  to  apply  only  to 
those  in  which  the  blood  escapes  into  the  bronchi.  Flint  restricts  the 
term  to  the  raising  of  blood,  and  blood  only.  The  most  important  con- 
ditions in  which  this  occurs  are :  («)  In  young  persons  apparently  in 
good  health,  a  more  or  less  profuse  hemoptysis,  or  a  slight  expectora- 
tion of  blood  for  several  days,  sometimes  occurs  without  discoverable 
lesion  of  the  lungs,  and  is  followed  for  many  years  by  good  health  and  no 
recurrence  of  the  hemorrhage;  (^)  tuberculosis.  This  has  been  con- 
sidered in  the  chapter  on  that  disease;  (r)  ulceration  of  the  larynx, 
trachea,  or  bronchi.  This  form  is  sometimes  rapidly  fatal  from  erosion 
of  a  branch  of  the  pulmonary  artery.  (^)  Pure  blood  is  sometimes 
expectorated  in  the  primary  stage  of  engorgement  in  acute  pneumonia, 
in  bronchitis,  bronchiectasis,  emphysema,  abscess,  gangrene,  or  cancer, 
less  frequently  in  sarcoma  of  the  lung.  (^)  Profuse  and  recurrent  hemor- 
rhage sometimes  occurs  during  the  course  of  valvular  disease  of  the 
heart,  more  frequently  with  mitral  stenosis  than  with  insufficiency  or 
aortic  lesions.  (/)  Aneurism  of  a  branch  of  the  pulmonary  artery  within 
the  lung  usually  terminates  in  a  fatal  hemoptysis.  Aneurism  of  the  arch 
of  the  aorta  sometimes  perforates  a  bronchus  and  produces  an  immedi- 
ately fatal  hemoptysis.  But  the  fatal  hemorrhage  is  sometimes  pre- 
ceded for  days  or  weeks  by  the  expectoration  of  a  small  quantity  of 
blood  from  pressure  or  erosion,  and  later  from  an  oozing  of  blood  through 
the  laminae  of  fibrin  which  alone  remain.  (^)  Vicarious  hemoptysis 
occasionally  replaces  menstruation,  especially  in  hysterical  and  anemic 
women,  or  for  a  time  after  removal  of  the  ovaries.  Hemopytsis  after 
cessation  of  the  menses  has  been  known  to  continue  for  several  years; 
but  it  sometimes  indicates  the  development  of  tuberculosis,  and  deception 
is  often  practiced  by  this  class  of  patients.  (/?)  Hemoptysis  has  been 
observed  in  connection  with  the  arthritic  diathesis  in  individuals  past 
50  years  of  age;  (/)  purpura  hemorrhagica  and  malignant  infections; 
(y)  parasitic  diseases  of  the  lungs, particularly  Distomum  Westermanni, 
met  with  especially  in  China  and  Japan. 

Exertion,  a  blow  upon  the  chest,  or  mental  excitement  is  sometimes 
the  immediate  cause  of  hemoptysis  in  a  person  already  predisposed  to 
it  by  pulmonary  disease. 

Symptoms.— In  a  majority  of  cases  the  hemorrhage  comes  on  sud- 
denly, often  at  night  and  during  sleep.  Sometimes  it  follows  a  fit  of 
coughing,  strong  vocal  effort,  unusual  excitement,  or  exertion.  The 
first  indication  of  it  is  usually  a  welling  up  into  the  mouth  of  the 
warm,  salty  fluid.  The  quantity  expectorated  varies  much  with  the  con- 
dition leading  to  the  hemorrhage.  Very  often  the  bleeding  ceases  after 
an  ounce  or  less  has  been  brought  up,  or  a  dram  or  less  may  be  ex- 
pectorated at  intervals  for  several  days ;  but  in  some  cases  of  continued 
hemoptysis,  repeated  losses  of  several  ounces  occur  at  short  intervals. 
When  an  aneurism  ruptures  into  the  lung,  there  is  usually  a  sudden 
gush  that  overwhelms  the  patient.  Only  a  small  part  of  the  blood  is 
usually  expectorated.  In  some  cases,  particularly  in  those  of  tubercu- 
lous origin,  the  blood  is  sometimes  poured  into  a  large  cavity  within 
the  lung,  and  death  occurs  from  the  hemorrhage,  without  expectoration 
of  blood. 


PULMONARY  HEMORRHAGE  401 

Coughing  is  generally  provoked  hy  the  hemoptysis;  the  patient  be- 
comes pale,  and  the  heart's  action  may  be  feeble,  but  this  is  usually  due 
to  the  alarm  that  is  naturally  occasioned,  and  not  to  the  loss  of  blood. 
After  a  hemoptysis  it  is  not  unusual  for  the  patient  to  vomit  some 
blood  that  has  been  swallowed;  sometimes  there  is  blood  in  the  stools 
for  a  day  or  two.  The  sputum  continues  to  be  streaked  with  blood 
for  a  few  days  after  cessation  of  the  hemorrhage. 

Diagnosis. — It  is  not  usually  difficult  to  distinguish  pulmonary 
hemorrhage  from  the  other  conditions  in  which  blood  is  expectorated. 
The  statement  of  the  patient  that  the  blood  has  been  coughed  up,  and 
not  vomited,  is  generally  correct,  and  the  appearance  of  the  blood  is 
quite  different.  In  hemoptysis  it  has  a  bright  red  color  and  usually 
contains  numerous  small  air-bubbles  which  may  give  it  a  frothy  appear- 
ance. Blood  from  the  stomach  is  generally  dark  and  clotted.  If  doubt 
exists,  or  if  the  blood  be  not  frothy,  it  is  well  to  examine  the  pharynx, 
after  having  the  patient  gargle  with  water,  for  blood  from  the  posterior 
nares  may  flow  back  into  the  throat.  Auscultation  of  the  chest  reveals 
moist  rales  in  the  affected  part  of  the  lung,  but  it  is  of  little  value 
unless  the  previous  condition  be  known,  and  the  patient  should  not  be 
disturbed  for  examination.     Percussion  should  not  be  practiced. 

Prognosis. — This  depends  entirely  upon  the  character  of  the  hemopty- 
sis. In  a  majority  of  cases  the  bleeding  ceases  spontaneously,  except 
when  it  is  from  a  vessel  of  considerable  size. 

Treatment — Rest  is  the  most  important  element  of  treatment.  The 
patient  should  be  placed  in  a  comfortable  position,  better  on  the  affected 
side,  in  order  to  avoid  aspiration  of  blood  into  the  healthy  lung.  He 
should  be  given  all  justifiable  assurance  of  recovery,  and  impressed  with 
the  importance  of  quiet  and  silence.  No  remedy  is  so  valuable  as  opium, 
for  it  induces  rest,  quiets  the  heart's  action,  and  allays  the  cough.  Mor- 
phin  may  be  administered  hypodermically  (gr.  J^  to  ^;  0.008 — 0.016), 
and  followed  with  heroin  (gr.  1-12;  0.005)  or  codein  (gr.  ]/^;  0.016) 
every  four  hours.  Aconite  is  often  indicated  to  quiet  and  strengthen 
the  heart's  action  and  to  reduce  the  pressure  in  the  pulmonary  artery. 
Digitalis,  ergot,  styptics,  are  all  more  or  less  positively  contraindicated. 
The  application  of  cold  to  the  chest  is  favored  by  some  writers,  but 
it  is  often  more  annoying  to  the  patient  than  beneficial.  Probably 
the  best  method  of  reducing  intra-arterial  tension  is  compression  of  the 
brachial  and  femoral  veins  by  means  of  an  elastic  band,  or  any  con- 
venient strap  or  bandage,  passed  around  the  arm  and  leg  and  drawn 
just  tightly  enough  to  arrest  the  venous  circulation  without  compressing 
the  artery.  Not  more  than  three  extremities  should  be  compressed  at 
the  same  time,  and  one  tourniquet  should  be  removed  every  fifteen 
minutes,  and,  if  necessary,  placed  upon  the  remaining  limb.  This  method 
is  often  effective  in  arresting  the  more  profuse  hemorrhages  which  can- 
not be  influenced  by  medicinal  means. 

The  diet  of  the  patient  should  be  light  and  nutritious.  Stimulants 
should  not  be  given,  unless  the  patient  is  in  an  extreme  condition  from 
the  loss  of  blood,  and  they  should  then  be  given  hypodermically.  A 
purge  is  generally  indicated;  repeated  purgation  is  especially  beneficial 
in  cases  of  continued  hemorrhage. 

2.    Pulmonary    Apoplexy    (Hemorrhagic    Infarct  of  the  Lung). — A 

26 


402  PRACTICE  OF  MEDICINE 

condition  in  which  the  tissue  of  a  hmited  portion  of  the  lung  is  infil- 
trated and  the  air-cells  more  or  less  completely  filled  with  blood  as  a 
result  of  embolism  or  thrombosis. 

Etiology. — This  affection,  which  is  not  to  be  regarded  as  a  hemor- 
rhage in  the  proper  use  of  the  term,  results  in  most  cases  from  the 
obstruction  of  a  branch  of  the  pulmonary  artery  with  either  a  thrombus 
or  an  embolus.  It  is  usually  a  sequel  of  heart  disease.  The  emboli  are 
septic  when  a  result  of  malignant  endocarditis  or  pyemia,  and  the  ex- 
travasation of  blood  in  such  cases  may  be  slight.  In  the  chronic  forms 
of  heart  disease  the  embolus  usually  consists  of  a  vegetation  from  one 
of  the  valves,  and  it  is  not  septic.  It  may  be  derived  from  a  remote 
thrombus,  as  that  of  the  femoral  vein,  after  typhoid  fever. 

Morbid  Anaiomy. — The  affected,  wedge-shaped  area  is  solidified,  dark 
red  in  color,  and  a  fibrinous  pleurisy  develops  over  its  base.  The 
subsequent  changes  are  those  peculiar  to  thrombosis.  (See  p.  15.)  If 
recovery  occur,  the  tissue  is  converted  into  a  firm  cicatrix.  In  some 
instances,  caseation  or  calcification  results,  or,  when  septic,  the  tissue 
breaks  down  and  forms  an  abscess  or  gangrene;  general  pyemia  is 
possible.    One  or  many  infarctions  may  occur  in  the  same  lung. 

Symptoms. — A  large  embolus  sometimes  causes  sudden  death  before 
an  infarction  has  had  time  to  develop.  On  the  other  hand,  the  vessel 
may  be  so  small  that  its  obstruction  produces  no  symptoms.  In  other 
cases  the  patient  is  seized  with  a  sudden,  severe  pain  in  the  lung,  urgent 
dyspnea,  sometimes  a  chill  and  slight  elevation  of  temperature.  Exam- 
ination reveals  circumscribed  dullness,  generally  in  the  region  to  which 
the  pain  is  referred,  and  tubular  breathing.  Mucus  streaked  with  blood 
is  usually  expectorated. 

Diagnosis. — The  differential  diagnosis  usually  rests  between  hemor- 
rhagic infarct  and  pneumonia.  Infarction  does  not  occur  as  a  primary 
disease.  In  pneumonia  the  initial  chill  is  more  severe,  the  fever  much 
higher,  the  lung  is  more  extensively  involved,  and  auscultation  reveals 
the  characteristic  crepitant  rale,  or  the  subcrepitant,  over  a  larger  area 
than  is  generally  aff'ected  in  infarction. 

The  treatment  is  directed  to  the  relief  of  pain,  weakness,  and  other 
symptoms  as  they  arise. 

BRONCHOPNEUMONIA. 

LOBULAR  PNEUMONLA,   CAPILLARY    BRONCHITIS,  CATARRHAL    PNEUMONIA. 

Definition.— An  acute  inflammation,  probably  of  infectious  origin, 
affecting  the  terminal  bronchi,  air-cells,  and  interstitial  tissue  of  isolated 
lobules,  or  groups  of  lobules  in  different  parts  of  the  lungs.  It  usually 
begins  in  the  mucous  membrane  of  the  bronchus  and  extends  to  the  air- 
ceMs. 

Etiology. — The  disease  is  regarded  by  many  investigators  as  an 
infection,  but  the  specific  organism  has  not  been  determined.  Several 
bacteria  have  been  more  or  less  regularly  found,  notably  the  Bacillus 
pneumoniae,  the  Micrococcus  lanceolatus,  and  the  staphylococci  and 
streptococci  of  suppuration.  A  mixed  infection  is  present,  as  a  rule. 
Bronchopneumonia  is  peculiarly  a  disease  of  the  extremes  of  hfe,  affect- 


BRONCHOPNEUMONIA  403 

ing  most  frequently  and  most  seriously  the  infant  and  the  very  aged. 
.  It  is  encountered,  however,  in  middle  adult  life,  particularly  as  a  second- 
ary affection.  It  may  occur  as  a  primary  disease,  and  Holt's  statistics 
indicate  that  the  remarkably  high  ratio  of  one  case  in  three  is  primary, 
without  previous  involvement  of  the  bronchi.  It  is  generally  secondary 
to  bronchitis. 

Primary  Bronchopneumonia. — This  form  of  the  disease  generally  oc- 
curs in  infants  and  is  probably  due  in  most  cases  to  pneumococcus 
infection.  Cases  following  prolonged  inhalation  of  ether,  smoke,  or  irri- 
tant vapors  are  generally  included  in  this  class. 

Secondary  bronchopneumonia  follows  bronchitis  of  the  larger  tubes 
and  is  a  common  sequel  of  such  affections  as  measles,  pertussis,  diph- 
theria, scarlet  fever,  influenza,  or  erysipelas,  and  it  not  infrequently 
follows  acute  ileocolitis  in  delicate,  improperly  fed  children,  or  those 
suffering  with  inherited  syphilis  or  tuberculosis.  Pulmonary  collapse 
or  atelectasis  from  any  cause  is  almost  invariably  followed  by  it.  In 
adults  it  is  often  encountered  as  a  result  of  influenza,  variola,  emphysema, 
occasionally  in  the  course  of  typhoid  fever,  or  as  a  terminal  affection 
in  bronchiectasis,  emphysema,  chronic  bronchitis,  asthma,  interstitial 
pneumonia,  and  tuberculosis.  Rickets  greatly  increases  the  susceptibility 
of  a  child,  and  long  confinement  to  bed  that  of  an  adult. 

Aspiration,  inhalation,  and  deglutition  pneumonia  are  terms  applied 
to  bronchopneumonia  developing  as  a  result  of  the  entrance  of  foreign 
bodies  into  the  bronchi.  This  occurs  when  small  particles  of  food  or 
drink  enter  the  larynx  when  it  is  benumbed  by  paralysis,  coma,  or  anes- 
thesia, or  when  the  epiglottis  is  ulcerated  by  syphilis  or  tuberculosis. 
Pus  or  fragments  of  neoplasms  and  blood  are  sometimes  aspirated  dur- 
ing operations  or  after  the  rupture  of  an  abscess  in  the  mouth  or 
pharynx.  The  exciting  cause  of  the  disease  is  not  so  much  the  irrita- 
tion caused  by  the  foreign  substance  as  the  bacteria  which  are  conveyed 
with  it. 

J.  N.  Hall  has  observed  severe  cases  of  bronchitis  and  bronchopneu- 
monia following  inhalation  of  sulphurous-acid  gas,  formaldehyd,  kero- 
sene, smoke  and  other  vapors. 

Morbid  >f/7afo/w/.— Although  the  bronchi  of  all  sizes  may  be  found 
in  a  state  of  hyperemia,  the  pneumonic  process  is  limited  to  the  terminal 
tubes  in  small  areas.  It  is  strictly  lobular  in  extent,  but,  owing  to  the 
involvement  of  adjacent  lobules,  areas  of  considerable  size  are  often 
found  to  be  involved,  particularly  along  the  margins  of  the  lungs. 
Sometimes  almost  an  entire  lobe  is  involved.  The  affected  areas  do  not 
fully  collapse  with  the  rest  of  the  lung  as  the  air  escapes ;  they  are  not 
solidified,  yet  they  are  firmer  and  do  not  crepitate  so  freely  as  the 
surrounding  lobules.  On  section,  they  appear  sHghtly  more  prominent, 
of  a  brighter  red  color  than  the  surrounding  tissue,  which  is  also  hyper- 
emic  for  a  variable  distance  (3  to  5  mm.).  Beyond  these  regions  of 
inflammation  the  lung  tissue  appears  normal.  The  medium  and  smaller 
bronchi  are  filled  with  mucopurulent  matter.  The  air-cells  are  more  or 
less  filled  with  serum,  which,  on  microscopic  examination,  is  found  to 
contain  numerous  leucocytes  and  desquamated,  swollen  endothelium. 
A  few  red  blood-corpuscles  are  occasionally  seen  and  possibly  a  trace 
of  fibrin,  but  not  to  the  extent  that  they  are  present  in  lobar  pneumonia. 


40  4  PRACTICE  OF  MEDICINE 

The  absence  of  fibrin  and  red  corpuscles  is  usually  a  distinguishing  fea- 
ture. The  air-cells  nearest  the  terminal  bronchus  are  the  most  densely 
filled  with  cellular  elements.  The  walls  of  the  alveoli  and  those  of  the 
terminal  bronchi  appear  swollen  on  account  of  the  distention  of  the 
capillaries  and  infiltration  with  leucocytes,  A  compensatory  emphysema 
is  generally  to  be  noted  in  the  uninvolved  portions  of  the  lungs.  The 
tracheobronchial  glands  are  usually  enlarged  and  inflamed,  a  fact  which 
explains  their  frequent  infection  with  tubercle  bacilH  after  the  infectious 
diseases  that  are  attended  with  bronchitis. 

In  aspiration  or  deglutition  pneumonia  the  infiltration  is  more  in- 
tense and  more  liable  to  become  suppurative. 

Termination. — Bronchopneumonia  terminates :  («)  In  a  rapid  resolu- 
tion; (J?)  in  caseation,  which  is  generally  only  a  form  of  tubercular 
infection;  {/)  in  suppuration  or  gangrene,  especially  in  the  deglutition 
or  aspiration  form;  or  (^/)  in  a  chronic  interstitial  pneumonia,  also 
more  commonly  seen  in  patients  who  were  previously  tuberculous. 

Symptoms. — The  primary  form  begins  in  a  previously  healthy  infant 
with  a  convulsion,  less  frequently  with  a  chill,  vomiting,  prostration, 
rapid  respiration,  often  reaching  60  in  a  minute,  and  elevation  of  tem- 
perature, possibly  reaching  104°  F.  (40°  C).  There  may  be  no  cough, 
and  infants  do  not  expectorate.  The  lesions  are  more  definitely  localized 
than  in  the  secondary  form.  Cerebral  symptoms,  dehrium,  photophobia, 
convulsions,  and  rigidity,  are  sometimes  so  pronounced  as  to  mask  the 
pulmonary  affection,  unless  proper  attention  is  given  to  the  rapid 
respiration  and  evidences  of  dyspnea.  The  case  often  terminates  with 
a  crisis  toward  the  end  of  a  week,  and  rapid  recovery  usually  follows. 
The  mortality  is  slight,  except  in  debilitated  infants.  The  disease  is  with 
difficulty  differentiated  from  lobar  pneumonia  during  life. 

The  secondary  form  occupies  a  more  positive  place  in  nosology. 
Following  a  bronchitis,  perhaps  during  convalescence  from  measles  or 
other  acute  infection,  the  temperature  rises,  the  breathing  and  pulse  be- 
come accelerated,  and  the  cough  m_ore  frequent  and  severe.  The  cough  is 
often  painful  and  the  infant  cries;  the  respiration  is  often  labored,  the 
lower  part  of  the  chest  is  drawn  in  by  the  diaphragm,  the  alae  of  the  nose 
vibrate,  and  cyanosis  often  develops.  Percussion  reveals  areas  of  dullness 
in  some  cases,  but  it  is  more  frequently  negative.  On  auscultation, 
numerous  subcrepitant  rales  are  heard,  particularly  over  the  base  of 
the  lungs  and  on  either  side  of  the  spine.  The  fever  generally  reaches 
103°  or  104°  F.  (39.5°— 40.0°  C),  and  the  skin  feels  hot  and  dry.  The 
thirst  is  urgent,  but  the  child  cannot  drink,  and  the  infant  refuses  the 
breast  on  account  of  the  rapid  respiration  and  dyspnea.  As  the  disease 
progresses,  often  within  24  to  48  hours  the  dyspnea  and  cyanosis  rap- 
idly increase.  The  right  ventricle  is  overcome  in  its  effort  to  main- 
tain the  circulation  in  the  lungs  and  becomes  increasingly  dilated.  The 
cyanosis  rapidly  deepens;  the  child  struggles  for  breath,  but  finally  sinks 
into  unconsciousness,  overcome  by  the  accumulation  of  carbon  dioxid 
in  its  blood;  the  breathing  becomes  less  labored,  the  mucus  is  more  fluid 
and  rattles  in  its  throat,  and  soon  the  heart  ceases,  from  paralysis. 

When  recovery  is  about  to  occur,  the  symptoms  gradually  ameliorate ; 
the  fever  subsides,  and,  usually  by  the  end  of  a  week,  convalescence  is 
established.    It  not  infrequently  happens,   however,  that  convalescence 


BRONCHOPNEUMONIA  405 

is  delayed  or  slow.  The  child  improves,  but  the  cough  persists  and  the 
emaciation  continues.  In  such  cases  there  may  be  ultimate  recovery, 
but  in  some  instances  a  portion  of  one  or  both  lungs  remains  perma- 
nently collapsed  or  a  chronic  interstitial  pneumonia  is  set  up;  some 
finally  die  of  exhaustion,  and  others  develop  tuberculosis. 

Diagnosis. — In  primary  cases  the  differentiation  generally  lies  between 
bronchopneumonia  and  lobar  pneumonia.  The  former  is  more  frequent 
in  young  infants,  the  latter  after  the  third  year.  Lobar  pneumonia  is 
usually  unilateral  and  confined  to  a  definite  region  of  one  lung,  which 
can  be  determined  by  the  dullness  on  percussion.  Bronchopneumonia 
affects  both  lungs,  and  there  is  often  a  general  tympanitic  note  without 
recognizable  dullness  anywhere.  The  cough,  pain,  and  fever  are  generally 
more  severe  in  the  lobar  form ;  yet  in  many  cases  the  distinction  is  ex- 
tremely difficult. 

In  secondary  cases  the  diagnosis  is  much  less  obscure.  The  disease 
follows  a  bronchitis  or  an  acute  infection.  The  onset  is  gradual,  the 
fever  is  more  moderate,  and  the  physical  signs  are  more  definite.  There 
may  be  little  or  no  recognizable  dullness,  but  fine  moist  rales  are  heard 
in  definite  areas  over  both  lungs.  Acute  tuberculosis,  in  the  beginning, 
is  sometimes  differentiated  with  difficulty,  although  the  temperature 
generally  remains  more  uniformly  high,  with  periodical  sweats,  especially 
at  night. 

Prognosis.— The  result  depends  largely  upon  the  condition  of  the  pa 
tient.  The  disease  is  very  fatal  in  the  extremes  of  life.  The  primary 
form  generally  terminates  in  recovery,  but  the  secondary  is  always  to 
be  feared. 

Prophylaxis.— The  liability  to  the  development  of  bronchopneumonia 
should  always  be  borne  in  mind  in  the  treatment  of  the  acute  infections, 
particularly  measles  and  whooping-cough.  Most  important,  probably, 
is  the  avoidance  of  exposure  to  cold,  or  rather  to  infection.  The  patients 
should  be  kept  warm  in  flannel  gowns,  and  they  should  not  be  released 
from  confinement  until  all  danger  has  passed.  The  sick-chamber  should 
not  be  allowed  to  become  cold  during  the  night.  The  regular  cleansing 
of  the  mouth  with  an  antiseptic  solution  is  also  important  in  all  dis- 
eases which  may  lead  to  bronchopneumonia. 

Treatment — The  patient  should  be  confined  to  bed  in  a  room  kept 
at  a  temperature  of  68°  F.  (20°  C),  and  the  air  should  be  kept  moist 
by  the  evaporation  of  water.  The  treatment  is  largely  symptomatic. 
The  fever  should  be  kept  within  bounds  by  the  administration  of  tinc- 
ture of  aconite,  TTLj  (0.06)  every  hour  or  two  according  to  the  age  and 
the  effect.  Cool  sponging  or  the  graduated  bath  serves  the  same  pur- 
pose, but  is  often  objected  to  and  condemned  as  the  cause  of  subsequent 
accidents.  The  coal-tar  antipyretics  should  be  avoided  on  account  of 
their  depressing  effects.  Opium  should  not  be  used,  unless  the  pain  and 
cough  cannot  be  controlled  by  any  other  means.  A  hot  poultice  around 
the  chest,  although  not  now  in  fashion,  or  the  more  cleanly  cotton 
jacket  which  may  be  pressed  out  of  hot  water  and  made  to  serve  as  a 
poultice,  often  relieves  the  pain,  and  is  probably  beneficial  in  other  re- 
spects. The  ice-poultice  and  cold-water  jacket  are  rarely  employed  in 
this  country.  A  simple  expectorant  consisting  of  ammonium  chlorid, 
gr.  i  to  ij  (0.06—0.12),  or  the  carbonate,  gr.  ^to  i   (o.oi — 0.06),  with 


4o6  PRACTICE  OF  MEDICINE 

sirup  of  ipecacuanha,  Tll,v  to  x  (0.3 — 0.6)  in  each  dose,  in  tolu  or  other 
sirup,  prevents  the  accumulation  of  tenacious  mucus,  providing  opiurn 
has  not  been  given,  and  thus  renders  the  cough  less  annoying.  An 
occasional  emetic  dose  of  wine  of  ipecacuanha  may  be  required  to  clear 
the  bronchial  tubes.  The  strength  of  the  patient  must  be  maintained 
with  nutritious  food,  chiefly  milk,  beef-juice,  broths,  and  egg  albumen. 
The  child  must  be  given  an  abundance  of  cold  water  to  drink,  and  brandy 
(t1],x  to  xv;  0.6— I. o,  to  an  infant)  should  be  given  at  regular  intervals, 
or  strychnin  may  be  administered  hypodermically.  The  bowels  should  be 
opened  with  calomel,  gr.  i-io  (0.006)  every  two  hours,  until  it  acts, 
and  kept  regular  during  the  illness  with  magnesium  citrate  or  other 
laxative.  When  cyanosis  appears,  every  effort  must  be  made  to  arouse 
the  patient  and  induce  coughing  or  vomiting.  If  the  mucus  can  be 
removed  from  the  tubes,  an  apparently  hopeless  case  will  sometimes 
recover. 

CHRONIC  INTERSTITIAL   PNEUMONIA. 

SCLEROSIS    (CIRRHOSIS)    OF   THE    LUNG,   FIBROUS    PNEUMONIA,    CHRONIC 
FIBROSIS  OF  THE  LUNG. 

Definiiion. — A  chronic  inflammation  of  the  interstitial  tissue  of  the 
lung  resulting  in  proliferation,  with  subsequent  contraction  and  diminu- 
tion of  air-space.    It  may  be  local  or  diffuse  in  character. 

£f/o/o^/.— The  disease  may  be  either  primary  or  secondary.  Primary 
cases  are  generally  due  to  the  inhalation  of  dust.  This  is  described 
in  the  following  chapter,  on  Pneumokoniosis.  Secondary  cases  occur  in 
the  course  of  chronic  tuberculosis,  syphihs,  chronic  bronchitis,  emphy- 
sema, or  chronic  pleurisy,  less  commonly  as  a  result  of  bronchopneu- 
monia or  lobar  pneumonia.  These  cases  are  usually  classed  as  examples 
of  the  diffuse  form. 

The  local  form  of  the  disease  is  met  with  as  a  result  of  penetrating 
wounds,  the  presence  of  a  foreign  body,  pressure  of  a  tumor  or  aneurism, 
or  the  irritation  of  healing  tubercular  nodules.  It  is  commonly  met 
with  around  bronchiectatic  cavities  and  beneath  a  thickened  pleura. 

Morbid  Anatomy.— The  essential  lesion  is  a  firm  mass  of  connective 
tissue  from  which  lines  of  similar  hyperplastic  tissue  usually  radiate 
into  the  surrounding  lung  substance.  The  primary  hyperplasia  may  take 
place  around  the  blood-vessels,  the  bronchial  walls,  the  interlobular 
spaces,  around  the  bronchioles,  or  in  the  pleura.  The  resulting  con- 
ditions are  described  under  two  forms,  the  massive  or  lobar,  and  the 
insular,  diffuse,  or  bronchopneumonic. 

(«)  The  massive  form  is  unilateral,  affecting  a  lobe  or  the  entire 
lung  and  producing  extreme  deformity  of  the  chest  with  approximation 
or  overlapping  of  the  ribs  and  depression  of  the  shoulder  in  extreme 
cases.  The  heart  is  drawn  toward  the  affected  side,  and  the  opposite 
lung  is  emphysematous,  while  the  affected  lung  is  often  shrunken  into 
an  extremely  small  mass  close  to  the  bodies  of  the  vertebrae.  In  cases 
of  long  standing  the  tissue  has  an  almost  cartilaginous  hardness.  Tu- 
bercular or  bronchiectatic  cavities  are  often  found  in  the  interior,  and 
within  these  aneurisms  of  the  pulmonary  artery  are  sometimes  found. 

(/^)  In  the  bronchopneumonic  form  the  areas  are  smaller,  less  indu- 


PNEUMOKONIOSIS  407 

rated,  and  usually  pigmented.    They  are  found  in  all  parts  of  the  lung,  ' 
as  a  rule,  but  may  be  confined  to  the  lower  lobes. 

Symptoms.— The  disease  is  an  exceedingly  chronic  one.  The  symp- 
toms are  most  pronounced  in  the  early  stage  of  its  development ;  after 
it  has  become  fully  established,  they  generally  subside  to  a  great  ex- 
tent and  the  individual  continues  in  fair  health  indefinitely.  There  is  a 
chronic  cough,  and  he  becomes  short  of  breath  upon  exertion,  as  in  going 
upstairs  or  walking  up  hill.  In  many  respects  the  case  resembles  one 
of  bronchiectasis,  especially  in  the  periodical  expectoration  of  large 
quantities  of  mucopurulent,  sometimes  fetid  matter.  The  nutrition 
generally  fails,  and  the  patient  then  appears  tuberculous,  especially  if 
hemorrhage  occurs,  a  possible  accident  in  nearly  half  the  cases.  But 
the  anemia  is  not  generally  so  marked.  The  absence  of  bacilli  is  the  dis- 
tinguishing feature. 

Physical  Signs. — These  are  exceedingly  variable.  In  extreme  cases 
the  affected  side  is  shrunken  and  immobile,  often  retracted  until  the 
ribs  overlap  and  the  opposite  side  seems  to  be  enlarged.  The  shoulder 
is  depressed,  and  the  spine  has  generally  a  lateral  curvature.  Percus- 
sion of  the  affected  side  may  reveal  flatness  or  partial  dullness,  with  a 
tympanitic  or  amphoric  quality  over  existing  cavities.  Over  the  other 
lung  the  tone  is  one  of  exaggerated  resonance  (tympanitic  resonance). 
The  breath-sounds  and  voice-sounds  depend  upon  the  condition  of  the 
contracted  lung.  The  vesicular  murmur  is  generally  replaced  by  a  tubu- 
lar, cavernous,  or  amphoric  breathing  in  the  apex  and  by  moist  rales 
at  the  base.  The  disease  ultimates  fatally  from  dilatation  of  the  right 
ventricle  and  dropsy,  or  from  exhaustion,  sometimes  from  amyloid  dis- 
ease of  the  viscera,  or  earlier  from  hemorrhage. 

Diagnosis. — Interstitial  pneumonia  cannot  be  mistaken  for  any  other 
disease  except  fibroid  phthisis,  in  which  the  lesions  and  physical  signs 
are  virtually  the  same,  with  the  additional  and  distinctive  feature,  the 
tubercle  bacillus. 

Treatment.  —Nothing  can  be  done  to  arrest  or  counteract  the  disease. 
Life  may  be  prolonged  by  residence  in  a  mild  climate,  where  the  liability 
to  bronchitis  is  least,  and  by  maintaining  the  nutrition  with  tonics,  the 
best  of  which  in  most  cases  is  codliver  oil.  When  the  cough  becomes 
troublesome  or  the  expectoration  fetid,  the  treatment  is  the  same  as  for 
chronic  or  fetid  bronchitis. 


PNEUMOKONIOSIS. 

ANTHRACOSIS,    SIDEROSIS,    CHALICOSIS,    MINER'S    LUNG,    KNIFE-GRINDERS' 

PHTHISIS,   ETC. 

Definition. — A  form  of  fibrous  induration  of  the  lung  due  to  the  in- 
halation of  particles  of  dust  in  various  occupations.  Anthracosis  sig- 
nifies induration  from  the  inhalation  of  coal-dust;  siderosis,  that  from 
the  inhalation  of  metallic  dust,  especially  iron,  as  from  the  emery- 
wheel;  chalicosis,  that  from  the  inhalation  of  mineral  dust,  as  in  stone- 
cutting. 

Etiology. — The  irritant  action  of  the  particles  of  dust  upon  the  con- 
nective tissue  of  the  lungs  is  probably  the  only  etiological  factor  in 


4o8  PRACTICE  OF  MEDICINE 

the  production  of  the  disease.    It  does  not,  however,  excite  proliferation 
with  the  same  degree  of  certainty  in  all  individuals. 

Morbid  Anatomy. — A  large  part  of  the  inhaled  dust  is  carried  back 
by  the  ciliated  epithelium  of  the  bronchial  tubes  and  expectorated. 
A  smaller  part  is  picked  up  by  phagocytes,  even  from  the  surface  of  the 
mucous  membrane.  Part  of  these  cells  then  pass  out  in  the  sputum, 
but  part  of  them  carry  their  burden  into  the  lymph-channels  and  to 
remote  organs,  particularly  the  bronchial  glands,  liver,  and  spleen.  In 
individuals  who  constantly  breathe  a  smoky  atmosphere,  the  surface  of 
the  lungs  becomes  deeply  discolored,  sometimes  jet-black,  as  a  result  of 
the  passage  of  particles  of  soot  into  the  lymph-spaces  and  thence  into 
the  connective  tissue  beneath  the  pleura.  The  particles  probably  do 
not  reach  the  air-cells  directly,  but  they  are  often  found  in  the  alveolar 
epithelium,  having  been  picked  up  by  these  cells  while  passing  through 
the  bronchial  tubes.  When  the  quantity  of  dust  that  gains  access  to 
the  bronchi  becomes  greater  than  can  be  carried  out  or  disposed  of  by 
the  carrier-cells,  much  of  it  is  stored  in  the  lymph-spaces  and  connective 
tissue  of  the  lungs,  beneath  the  pleura,  around  the  bronchi  and  air-cells. 
The  irritation  produced  excites  proliferation  of  the  tissue  and  a  fibro- 
sis is  produced,  much  like  that  of  chronic  interstitial  pneumonia,  ex- 
cept that  the  new  fibrous  tissue  is  always  deeply  pigmented.  Later,  this 
tissue  often  undergoes  necrosis,  and  cavities  are  formed  in  the  lungs. 
The  lesions  are  bilateral;  the  bases  of  the  lungs  are  more  extensively 
affected  than  other  parts,  but  nodules  and  cavities  are  not  infrequently 
found  scattered  through  all  parts  of  both  lungs.  Chronic  bronchitis  is 
a  constant  accompaniment,  and  there  is  generally  emphysema.  Some- 
times the  necrotic  cavities  become  tubercular. 

Symptoms. — The  clinical  features  of  the  case  are  the  same  as  those 
of  chronic  bronchitis  with  emphysema,  except  that  there  is  a  more  pro- 
fuse expectoration  of  black  or  otherwise  discolored  mucopurulent  spu- 
tum. This  discoloration  continues  for  a  long  time  after  the  patient 
has  abandoned  his  dusty  employment.  Examination  of  the  sputum  re- 
veals numerous  leucocytes,  bronchial  and  occasional  alveolar  epithelial 
cells  containing  dust-particles.  The  presence  or  absence  of  tubercle  ba- 
cilli depends  wholly  upon  the  presence  of  tubercular  infection.  Dyspnea 
is  often  a  prominent  symptom,  but  it  depends  for  the  most  part  upon 
the  emphysema.  More  or  less  pronounced  asthmatic  attacks  occur  in 
many  cases.  The  chest  often  becomes  barrel-shaped,  as  a  result  of  the 
emphysematous  condition. 

Treatment. — The  case  should  be  treated  as  one  of  chronic  bronchitis 
with  emphysema.  The  condition  of  the  lungs  cannot  be  modified  by 
treatment. 

EMPHYSEMA. 

Definition. — Pulmonary  emphysema  is  a  condition  of  the  lungs  charac- 
terized by  distention  or  dilatation  of  the  infundibula  and  alveoli,  asso- 
ciated, when  permanent,  with  atrophy  of  their  walls.  Five  more  or  less 
distinct  forms  of  the  disease  are  recognized,  namely,  the  compensatory, 
hypertrophic,  atrophic,  acute  vesicular,  and  interstitial. 

I.  Compensatory  Emphysema.— This  condition  is  produced  in  one 


EMPHYSEMA 


409 


lung  or  in  a  part  of  either  lung  whenever  some  other  part  is  prevented 
from  expanding  during  respiration.  It  is  compensatory  in  that  it  en- 
ables the  lung,  by  overexpansion,  to  fill  the  space  that  should  be  filled 
by  the  part  whose  movement  has  been  arrested.  A  temporary  condition 
of  emphysema  is  produced  in  the  normal  portions  of  the  lungs :  (a)  In 
the  presence  of  atelectasis  or  collapse;  (^)  in  all  the  acute  conditions 
attended  with  consolidation  or  bronchial  obstruction,  as  in  the  pneu- 
monias; and  (r)  a  more  persistent  form  occurs  in  connection  with 
pleuritic  adhesions,  hydrothorax,  empyema,  pneumothorax,  chronic 
interstitial  pneumonia,  and  tuberculosis.  In  the  purely  compensatory 
condition  the  alveolar  walls  are  merely  distended  without  undergoing 
atrophy,  and  return  to  their  normal  condition  with  the  removal  of 
the  exciting  cause. 

2.  Hypertrophic  Emphysema.— The  lungs  in  this  condition  are  much 
enlarged  by  the  distention  of  their  air-cells.  The  condition  is  known 
also  as  substantive  or  idiopathic  emphysema,  and  it  is  the  form  that 
was  described  by  Sir  William  Jenner  as  the  "  large-lunged  emphysema," 
in  contradistinction  to  the  atrophic  or  "  small-lunged  emphysema." 

Etiology. — A  hereditary  predisposition  to  the  disease,  in  the  form  of 
a  congenital  defect  in  the  structure  or  nutrition  of  the  tissue  of  the  lungs, 
is  generally  believed  to  exist,  for  the  disease  does  not  develop  in  all 
individuals,  or  to  the  same  extent,  under  the  same  influences.  The 
disease  very  commonly  develops  in  early  life  and  especially  in  the  chil- 
dren of  those  affected  with  it.  It  is  by  no  means  uncommon,  however, 
later  in  life,  and  may  develop  in  the  aged. 

The  next  important  factor  in  etiology  is  an  increased  pressure  within 
the  air-cells.  This  may  result  from  either  inspiratory  or  expiratory 
force,  but  it  is  doubtless  more  readily  and  more  commonly  produced 
by  forcible  expiration,  such  as  occurs  in  pertussis,  asthma,  chronic 
coughs,  and  in  playing  wind-instruments,  glassblowing,  and  other  occu- 
pations requiring  prolonged  acts  of  blowing.  Mechanical  causes  are 
believed  to  be  eff'ective  only  in  the  presence  of  a  weakened  power  of 
resistance  in  the  lung.  Dilatation  of  the  heart,  a  condition  usually  en- 
countered as  a  result  of  emphysema,  and  alcoholism  are  regarded  by 
some  writers  as  predisposing  causes  in  some  instances.  The  presence  of 
adenoid  vegetations  in  the  nasopharynx  is  at  least  a  probable  cause 
in  a  child  with  inherited  predisposition. 

Morbid  Anatomy. — The  chest  has  a  barrel-shape,  a  condition  attribut- 
ed by  some  writers  to  the  expansion  of  the  lungs  within,  by  others  to 
the  action  of  the  external  respiratory  muscles.  The  dilatation  of  the 
lungs  is  generally  so  great  that  the  pericardium  is  completely  con- 
cealed by  the  overlapping  of  their  anterior  margins,  when  the  chest  is 
opened.  They  do  not  collapse,  but  pit  on  pressure,  on  account  of  a  com- 
plete loss  of  elasticity.  Immediately  under  the  pleura  can  be  seen  numer- 
ous enlarged  air-vesicles,  varying  in  diameter  from  i  to  3  or  4  mm. 
Along  the  margins  and  over  the  inner  surfaces,  near  the  heart,  there 
are  bullae,  varying  in  size  from  that  of  a  pea  to  that  of  a  hen's  c:gg, 
which  have  resulted  from  a  coalescing  of  several  smaller  vesicles,  frag- 
ments of  whose  walls  can  be  seen  in  the  interior  with  a  suitable  lens 
or  in  microscopic  section.  Other  histological  changes  are  also  to  be 
noted.    With  the  distention  of  the   air-cells   the   capillary    vessels    are 


41  o  PRACTICE  OF  MEDICINE 

stretched  longitudinally  at  the  expense  of  their  caliber.  As  a  result, 
the  network  becomes  imperfect  and  gradually  disappears  from  the  larger 
sacs.  The  elastic  tissue  of  the  distended  air-cells  is  also  lost — some 
regard  it  as  congenitally  defective;  and  the  epithelium  is  reduced  to  a 
delicate  squamous  layer  lining  the  inner  surface  of  the  bullae.  As  a 
result  of  the  destruction  of  the  capillary  circulation,  increased  action  is 
thrown  upon  the  right  ventricle.  This  leads  to  hypertrophy  and  in  time 
to  dilatation.  In  the  more  chronic  cases  both  sides  of  the  heart  become 
hypertrophied,  but  the  right  side  is  most  dilated.  The  pulmonary 
artery  also  yields  to  the  increased  tension  within  it  and  becomes  en- 
larged.   Atheromatous  changes  are  commonly  found  in  its  walls. 

The  bronchi  also  show  important  changes.  The  mucous  membrane 
in  the  larger  tubes  is  often  greatly  thickened  and  indurated.  The  longi- 
tudinal elastic  fibers  sometimes  stand  out  like  cords.  Around  the  tubes 
there  is  generally  a  fibrous-tissue  hyperplasia,  a  sclerosis,  which  leads  to 
dilatation,  particularly  of  the  smaller  bronchi.  Atelectasis  is  some- 
times present,  but  it  is  not  a  frequent  result  of  emphysema.  The  more 
remote  organs,  especially  the  liver  and  kidneys,  are  found  in  a  more 
or  less  advanced  stage  of  chronic  passive  hyperemia. 

Symptoms. — Emphysema  is  an  exceedingly  chronic  disease,  and  its 
symptoms  from  time  to  time  depend  largely  upon  the  existence  of  bron- 
chitis, the  extent  to  which  the  circulation  in  the  lung  is  impaired,  and 
the  development  of  comphcations.  There  is  usually  a  considerable  period, 
especially  in  childhood,  during  which  the  patient  experiences  compara- 
tively little  discomfort.  The  muscular  system  may  be  well  developed 
and  strong,  but  the  body  generally  becomes  emaciated  as  the  disease 
progresses.  The  most  important  symptoms  are  dyspnea,  cyanosis,  and 
bronchitis. 

(a)  Dyspnea  may  be  almost  constant,  but  in  many  cases  it  is  com- 
plained of  only  after  a  full  meal  or  after  exertion.  It  is  at  first  largely 
expiratory  in  character,  but  later  assumes,  in  many  instances,  the  form 
of  asthmatic  seizures,  with  both  inspiratory  and  expiratory  obstruction. 
A  distinct  wheezing  or  rattling  rhoncus  is  often  audible  to  the  patient, 
and  it  can  sometimes  be  heard  at  a  distance  of  several  feet  from  him, 
most  markedly  with  expiration. 

(<5)  The  cyanosis  is  a  common  and  often  a  most  striking  feature  of 
the  disease.  It  accompanies  the  dyspnea,  but  is  often  severe  beyond 
all  comparison  with  that  condition.  The  patient  often  shows  little 
discomfort;  he  may  be  able  to  walk  about  when  his  face  is  puffy  and 
his  lips  and  finger-tips  are  blue.  So  deep  cyanosis  is  not  often  seen 
except  as  a  result  of  anilin-poisoning,  congenital  heart-lesions,  or  the 
most  advanced  organic  cardiac  or  pulmonary  disease,  and  then  only  in 
persons  confined  to  bed. 

(^)  The  bronchitis  is  most  troublesome  in  winter,  often  disappearing 
almost  completely  during  the  summer.  It  is  excited  by  the  slightest 
exposure  and  assumes  a  severity  that  is  unusual  in  a  previously  healthy 
person,  intensifying  the  dyspnea  and  cyanosis  and  often  inducing  severe 
paroxysms  of  asthma.  With  the  advance  of  age  it  becomes  a  more 
dangerous  condition  and  may  ultimately  lead  to  a  fatal  bronchopneu- 
monia. 

Physical  Signs. —Inspection.— The  appearance  of  the  chest  is  so  typical 


EMPHYSEMA  411 

as  not  to  be  mistaken.  It  is  the  so-called  barrel-shaped  chest.  The 
thorax  is  round  and  deeper  than  the  normal.  The  anteroposterior  di- 
ameter may  exceed  the  transverse;  the  ribs  are  more  horizontal,  and 
the  interspaces  are  widened.  The  sternum  and  clavicles  are  prominent, 
and  fossae  above  them  are  deep.  The  back  is  rounded,  the  shoulders  are 
raised  and  drawn  forward.  The  respiratory  muscles,  including  all  the 
accessory  muscles,  are  strong  and  stand  out  prominently.  Their  action 
during  active  respiration  is  exaggerated,  and  the  thorax  is  drawn  up 
as  a  solid  frame;  there  is  little  or  no  expansion.  Tranquil  respiration 
is  carried  on  almost  entirely  by  the  diaphragm.  The  expiration  is  pro- 
longed, and  the  thorax  sinks  more  slowly  than  it  rises.  During  inspira- 
tion, the  upper  part  of  the  abdomen  often  remains  fixed,  or  it  may 
sink,  and  the  suprasternal  fossa  is  usually  drawn  in.  A  transverse 
curve  running  across  the  abdomen  at  the  level  of  the  last  ribs  has  been 
noted.  The  veins  of  the  neck  are  distended  and  usually  pulsate.  The 
apex  beat  of  the  heart  is  not  visible,  but  there  is  usually  a  strong 
epigastric  pulsation. 

Palpation  reveals  but  slight  vocal  fremitus,  the  absence  of  the  apex 
beat,  a  strong  impulse  beneath  the  lower  portion  of  the  sternum,  and  a 
forcible  epigastric  pulsation. 

Percussion  elicits  a  peculiar  type  of  resonance  which  is  described  by 
different  authors  as  increased  resonance,  hyper-resonance,  or  tympanitic 
resonance.  The  quality  is  more  or  less  drumlike  and  peculiar  to  the 
emphysematous  chest.  It  partakes  of  the  tympanitic  quality  as  com- 
pared to  the  normal  percussion  note,  but  it  is  not  tympanitic  when 
compared  with  that  of  the  abdomen.  The  distention  of  the  lungs  is 
revealed  by  the  obliteration  of  the  cardiac  dullness  and  the  lowering 
of  the  upper  margins  of  the  liver  and  splenic  dullness. 

Attscultation. — The  vesicular  quality  of  the  respiratory  murmur  is 
lost.  In  the  absence  of  bronchitis,  the  respiration  may  be  almost  in- 
audible, but  there  is,  as  a  rule,  a  distinct  prolongation  of  the  expiratory 
murmur,  generally  accompanied  with  wheezing  and  coarse,  sonorous, 
and  sibilant  rales.  When  bronchitis  is  present,  the  respiratory  sounds 
are  replaced  by  the  moist  rales  belonging  to  that  affection.  The  heart- 
sounds  can  be  distinctly  heard  and  may  be  normal,  with  the  exception 
of  an  accentuation  of  the  pulmonary  second  sound;  but  in  the  later 
stages  of  the  disease  there  is  often  a  tricuspid  regurgitant  murmur. 

Diagnosis. — The  disease  cannot  be  mistaken  for  any  other.  Even 
when  the  physical  signs  are  masked  by  those  of  bronchitis  the  condition 
is  fully  revealed  by  the  appearance  of  the  thorax,  the  absence  of  the 
apex  beat,  and  the  disappearance  of  the  usual  boundaries  of  the  solid 
organs. 

Prognosis. — Emphysema  is  incurable;  under  the  most  favorable  con- 
ditioris  it  is  slowly  progressive,  for  the  elasticity  of  the  lung  cannot  be 
restored,  and  the  damage  to  the  pulmonary  circulation  is  a  permanent 
one. 

Treatment. — When  the  disease  is  encountered  early,  as  in  a  young 
child  with  asthma,  a  thorough  examination  should  be  made  of  the 
upper  respiratory  passages;  nasal  defects  and  pharyngeal  adenoids  or 
polyps  should  be  removed  in  the  hope  of  abating  the  causal  influence. 
After  the  disease  has  been  developed,   nothing  can  be  done,    and    the 


412  PRACTICE  OF  MEDICINE 

treatment  is  directed,  for  the  most  part,  toward  the  accompanying  bron- 
chitis. The  emphysematous  patient  should  reside  in  a  warm,  dry  cU- 
mate  where  he  can  best  escape  the  many  influences  which  excite  bron- 
chitis. The  diet  should  be  regulated  with  reference  to  the  prevention 
of  constipation  and  flatulency.  Starches  and  sugar  should  be  restricted 
in  quantity.  Strychnin  is  a  valuable  tonic,  assisting  the  weakened  heart 
to  perform  its  function.  For  extreme  cyanosis,  oxygen  may  be  inhaled, 
but  there  is  no  better  remedy  in  young,  robust  patients  than  free  vene- 
section. 

3.  Atrophic  Emphysema. — This  form  of  ephysema  is  purely  a  senile 
change,  a  part  of  the  general  wasting  which  marks  the  closing  years 
of  a  long  life.  It  occurs  in  either  sex  and  is  attended  with  atrophic 
changes  in  nearly  all  other  tissues  of  the  body.  These  patients  usuall)^ 
give  a  history  of  winter  cough,  with  greater  or  less  difficulty  of  breath- 
ing, for  many  years.  The  chest  is  not  expanded,  but  small,  and  the 
obliquity  of  the  ribs  is  increased.  It  is  only  the  condition  of  the  lungs 
that  is  characteristic  of  emphysema.  In  a  typical  case  the  air-cells 
are  found  to  have  coalesced  into  a  series  of  large  bullae.  The  blood- 
vessels have  undergone  atrophy,  as  in  the  hypertrophic  form  of  the  dis- 
ease. 

4.  Acute  Vesicular  Emphysema. — A  condition  in  which  the  air-cells 
are  acutely  distended  as  a  result  of  strong  expiratory  efforts  in  some 
cases  of  bronchitis  affecting  the  smaller  tubes,  bronchopneumonia, 
cardiac  dyspnea,  angina  pectoris,  or  asphyxia.  The  lungs  are  much  en- 
larged after  death.  The  condition  can  sometimes  be  recognized  during 
life  by  the  emphysematous  resonance,  increase  in  area,  prolonged  expira- 
tion and  loud  sibilant  rales  over  all  parts  of  the  chest. 

5.  Interstitial  Emphysema. — This  form  of  emphysema,  which  corre- 
sponds to  surgical  emphysema,  results  from  the  passage  of  air  into  the 
interstitial  tissue  of  the  lungs.  It  is  generally  caused  by  an  extreme 
expiratory  effort,  as  in  whooping-cough,  bronchopneumonia,  convulsions, 
parturition,  defecation,  or  lifting,  a  rupture  of  air-vesicles  being  pro- 
duced. The  air  accumulates  in  minute  bubbles  beneath  the  pleura  and 
in  the  interlobular  spaces.  Sometimes  it  finds  its  way  into  the  medi- 
astinum and  thence  into  the  cellular  tissue  of  the  neck.  After  trache- 
otomy an  interstitial  emphysema  sometimes  develops  from  the  passage 
of  the  air  down  along  the  trachea  to  the  lungs.  Pneumothorax  may 
also  result  from  an  interstitial  emphysema. 

PULMONARY  COLLAPSE. 

ATELECTASIS. 

The  term  atelectasis  signifies  the  airless  condition  of  the  lung  before 
birth,  or  as  a  result  of  the  failure  to  establish  respiration  after  birth. 
Pulmonary  collapse,  on  the  other  hand,  applies  to  the  collapse  of  a  por- 
tion of  a  lung  when  a  bronchial  tube  becomes  obstructed  by  a  foreign 
body,  a  plug  of  mucus,  or  from  other  cause,  and  to  the  occasional 
collapse  of  a  portion  of  one  or  both  lungs  in  a  feeble,  syphilitic  child. 
Collapse  may  be  caused  also  by  the  pressure  of  tumors,  hydrothorax, 
empyema,  or  pneumothorax.    The  condition  is  then  known  as  carnifi- 


ABSCESS  OF  THE  LUNG  '  413 

cation.  Bronchopneumonia  is  a  common  sequel  of  partial  collapse. 
A  collapsed  lung  may  regain  its  normal  condition,  especially  when  due 
to  hydrothorax,  after  early  removal  of  the  compressing  fluid,  but  later 
it  becomes  firmly  adherent,  and  expansion  is  permanently  prevented. 
The  collapsed  lung  contains  little  or  no  air,  and  has  a  dark  red  color 
from  engorgement  with  blood.  The  condition  is  usually  a  part  or  sequel  of 
some  other  condition,  and  rarely  calls  for  separate  treatment.  The  only 
measure  for  its  relief,  in  fact,  is  the  removal  of  the  cause,  and  this  is 
rarely  possible. 

ABSCESS  OF  THE   LUNG. 

Etiology. — i.  Suppuration  of  the  lung  results  from  septic  infection 
after  inflammation.  It  is  sometimes  a  sequel  of  lobar  pneumonia,  more 
frequently  of  lobular,  and  exceedingly  common  after  deglutition  or  as- 
piration pneumonia.  The  form  of  aspiration  pneumonia  most  fre- 
quently leading  to  suppuration  is  that  arising  from  the  entrance  of  pus 
or  septic  matter  of  any  kind  during  operations  upon  the  nose  or  throat. 
Multiple  abscesses  varying  in  size  from  an  inch  to  two  inches  (2.5 — 
5.0  cm.)  in  diameter  are  generally  produced,  but  a  solitary  abscess  is 
occasionally  met  with. 

2.  Embolic  or  metastatic  abscesses  are  generally  a  part  of  a  pyemic 
infection,  multiple  septic  emboli  reaching  the  lungs  through  the  circula- 
tion from  more  or  less  remote  sources,  as  from  a  malignant  endocarditis^ 
an  endophlebitis,  or  pyonephrosis.  The  abscesses  are,  therefore,  multiple 
and  may  be  extremely  numerous.  They  are  generally  found  immediately 
beneath  the  pleura.  The  lodgment  of  an  embolus  at  first  produces  a 
hemorrhagic  infarction,  but  owing  to  the  septic  nature  of  the  obstruc- 
tion the  subsequent  changes  are  suppurative.  The  pleura  is  at  once 
afi^ected  with  a  septic  fibrinous  inflammation,  and  perforation  is  not 
uncommon,  with  the  production  of  pneumothorax. 

3.  Abscess  results  also  from  perforation  of  the  lung  from  without, 
the  lodgment  of  foreign  bodies,  especially  bullets,  or  from  the  rupture 
of  a  subdiaphragmatic  or  hepatic  abscess  or  echinococcus  cyst. 

4.  Finally,  one  of  the  most  common  types  of  pulmonary  suppuration 
is  that  associated  with  tuberculosis. 

Symptoms. — Suppuration  of  the  lung  following  an  inflammatory  con- 
dition is  usually  announced  by  a  return  of  the  fever,  pain,  and  dys- 
pnea, with  rapid  respiration.  Later,  pus  is  found  in  the  sputum,  or,  if 
the  abscess  be  large,  a  correspondingly  large  quantity  of  pure  pus  may 
be  expectorated.  The  pus  is  often  extremely  offensive.  Multiple  pyemic 
abscesses  are  often  unrecognizable  on  account  of  the  intense  general 
pyemic  condition  that  is  present.  The  discovery  of  pus  in  the  sputum, 
with,  perhaps,  fragments  of  elastic  tissue,  is  highly  diagnostic  of  the 
condition. 

Prognosis. — Embolic  and  aspiration  abscesses  are  almost  invariably 
fatal,  but  recovery  sometimes  occurs  in  those  following  pneumonia  or 
foreign  bodies,  after  surgical  treatment  or  a  long  process  of  spontaneous 
healing. 

Treatment. — Medicinal  treatment  is  practically  useless.  The  quantitj 
and  the  offensive  character  of  the  expectorated  pus  are  sometimes  mark- 


414  '  PRACTICE  OF  MEDICLNE 

edly  diminished  after  the  administration  of  calcium  sulphid,  gr.  j  (0.06) 
t,  i.  d.,  but  when  the  abscess  can  be  reached  the  proper  treatment  is 
incision  and  the  estabHshment  of  drainage. 

GANGRENE  OF  THE   LUNG. 

Definiiion.  —  h.  locaHzed  or  diffuse  putrefactive  necrosis  affecting  a 
greater  or  less  portion  of  the  lung. 

Etiology. — Gangrene  is  always  a  secondary  affection;  it  does  not 
attack  previously  healthy  lung  tissue.  It  arises  from  the  entrance  of 
the  bacteria  of  putrefaction  into  a  tissue  already  necrotic.  It  is  a 
common  sequence  of:  (rt;)  Aspiration  pneumonia;  occasionally  of  (i^) 
lobar  pneumonia  in  a  previously  debilitated  subject ;  more  commonly  of 
i^c)  bronchopneumonia,  (i^)  bronchiectasis  or  fetid  bronchitis,  (^)  embo- 
lism or  thrombosis  of  the  pulmonary  artery,  especially  when  the  embolus 
is  derived  from  a  gangrenous  focus,  or  (y)  cancer.  It  sometimes  follows 
(^)  perforating  wounds,  (/^)  rupture  into  a  bronchus  of  an  esophageal 
or  other  ulcer,  (/)  the  perforation  of  an  empyema  or  hydatid  cyst, 
(y)  the  pressure  of  an  aneurism  or  other  tumor.  (/&)  As  a  result  of 
tuberculosis,  it  is  infrequent  only  in  comparision  to  the  prevalence  of 
the  latter  disease.  (/)  It  sometimes  develops  during  convalescence 
from  fevers  of  long  duration,  when  the  exciting  cause  cannot  be  deter- 
mined. After  typhoid  fever,  it  is  generally  due  to  the  obstruction  of  a 
large  branch  of  the  pulmonary  artery.  The  disease  is  most  likely  to 
affect  elderly  persons  debilitated  by  chronic  wasting  disease,  especially 
diabetes,  or  by  alcoholism,  but  it  sometimes  occurs  in  the  young. 

Morbid  Anatomy. — (a)  The  diffuse  form  is  rare,  being  occasionally  met 
with  after  lobar  pneumonia,  or  after  the  plugging  of  a  large  branch  of 
the  pulmonary  artery.  A  greater  part  or  the  whole  of  one  lung  is  con- 
verted into  a  dark  blue  or  greenish  black,  extremely  fetid,  pultaceous 
mass,  disintegrated  at  the  center  and  not  definitely  separated  from 
the  surrounding  tissue.  (^)  In  the  circumscribed  form,  the  necrotic 
tissue  is  more  clearly  defined ;  a  distinct  sphacelus  is  sometimes  formed. 
The  surrounding  tissue  is  deeply  congested,  often  solidified,  and  beyond 
this  area  the  lung  is  edematous.  The  original  embolus  can  sometimes 
be  found,  and  it  is  not  unusual  to  discover  a  rupture  of  a  blood-vessel 
or  perforation  of  the  pleura  in  cases  dying  from  hemorrhage.  Bron- 
chitis is  a  constant  accompaniment.  Abscesses  are  not  infrequently 
found  also  in  the  brain,  liver,  or  spleen. 

Symptoms. — The  development  of  putrefaction  upon  a  previous  pul- 
monary disease  is  promptly  announced  by  the  extremely  fetid  expectora- 
tion. The  condition  is  occasionally  encountered  post  mortem,  however, 
in  cases  which  gave  no  indication  of  it  during  life.  The  sputum  is 
usually  profuse,  thin,  greenish,  containing  mucus,  pus,  elastic  tissue, 
fat-crystals,  granular  debris,  bacteria  of  putrefaction,  and  sometimes 
altered  blood.  After  standing,  the  sputum  separates  into  three  layers, 
the  solid  matter  sinking  to  the  bottom;  a  middle  greenish  fluid,  and  a 
supernatant  brownish  froth.  Fragments  of  necrotic  lung  tissue  are 
sometimes  expectorated,  and,  when  a  blood-vessel  has  been  eroded,  a 
profuse  hemorrhage  occurs.  Moderate  fever  is  always  present.  The 
patient  becomes  rapidly  emaciated  and  anemic,  but  does  not,  as  a  rule, 


NEOPLASMS  OF  THE  LUNG  415 

have  much  pain.  The  cough  is  almost  constant,  sometimes  strong  and 
ineffectual,  interfering  with  sleep.  Sepsis  generally  develops,  with  re- 
peated chills,  increased  fever,  sweats,  and  delirium.  The  physical  signs 
are  not  always  distinctive.  A  severe  bronchitis  is  invariably  present,  as 
indicated  by  the  cough,  and,  when  there  has  been  great  destruction  of 
the  lung,  the  signs  of  a  cavity  may  be  elicited  by  percussion  and  auscul- 
tation. 

The  prognosis  depends  upon  the  previous  condition  of  the  patient 
and  the  cause  and  character  of  the  gangrene.  Recovery  sometimes 
occurs  in  a  young,  previously  healthy  person  after  the  case  has  long 
appeared  hopeless,  and  after  extensive  destruction  of  lung  tissue,  but 
in  the  debilitated  subject  of  diabetes  or  other  constitutional  disease  a 
fatal  result  is  inevitable. 

Treatment. — The  patient  must  be  immediately  isolated  in  a  well- ven- 
tilated apartment,  the  air  of  which  should  be  charged  with  the  vapor 
of  carbolic  acid,  guaiacol,  turpentine,  or  formaldehyd ;  or  one  of  these 
disinfectants  may  be  dropped  upon  a  respirator  worn  by  the  patient. 
The  strength  of  the  patient  must  receive  especial  attention.  The  food 
should  be  liquid  and  of  the  most  nutritious  quality.  Whisky  and 
strychnin  should  be  administered  freely.  The  advisability  of  surgical 
measures  should  be  considered  early  when  the  gangrenous  cavity  is  near 
the  surface.  Antiseptic  solutions  may  be  injected  directly  into  it,  or 
the  cavity  may  be  opened  and  drained  as  an  abscess,  providing  the  con- 
dition of  the  patient  will  permit. 

NEOPLASMS  OF  THE  LUNG. 

1.  Benign  neoplasms  are  rare.  Fibromata,  myxomata,  enchondro- 
mata,  osteomata,  and  adenomata  have  been  encountered.  Dermoid 
cysts  have  occasionally  been  met  with. 

2.  Malignant  growths  may  be  either  primary  or  secondary.  The 
primary  are  extremely  rare.  Secondary  carcinoma,  epithelioma,  or  sar- 
coma is  more  common.  Cancer  reaches  the  lung  by  direct  growth 
through  the  chest-wall,  or  through  the  lymph-channels  from  a  primary 
source  in  the  breast,  esophagus,  stomach,  or  liver.  It  usually  appears 
in  the  form  of  multiple  small  nodules  in  the  pleura  of  one  or  both 
lungs,  which  increase  in  size  and  extend  deeper,  sometimes  giving  rise 
to  bronchopneumonia,  suppuration,  or  gangrene.  Secondary  sarcoma 
reaches  the  lung  by  direct  extension  from  the  ribs  or  other  adjacent 
tissues,  or  through  the  blood-vessels  from  remote  parts  of  the  body. 
It  constitutes  one  of  the  most  frequent  locations  of  secondary  growths. 
\\Tien  a  direct  extension,  the  growth  is  usually  single ;  when  metasta- 
tic, there  may  be  a  large  number  of  nodules  in  both  lungs.  Pleurisy, 
either  malignant,  serous,  fibrinous,  or  hemorrhagic,  is  an  almost  con- 
stant accompaniment  of  either  form  of  malignant  disease.  Sarcoma 
occurs  most  frequently  in  early  and  middle  life,  but  cancer  is  infrequent 
under  the  age  of  40.  The  secondary  form  is  much  more  commonly  met 
with  in  women. 

Symptoms. — The  clinical  manifestations  of  malignant  disease  are 
indefinite.  In  many  cases  the  disease  exists  for  some  time  without 
producing  recognizable  disturbance.    Dyspnea  is  often  one  of  the  first 


41 6  PRACTICE  OF  MEDICINE 

indications  of  it.  Cough  is  usually  present,  and  it  may  be  painful  and 
ineffectual.  There  is  sometimes  a  brownish,  "  prune-juice"  expectoration 
that  is  regarded  as  highly  diagnostic  by  some  writers.  Pain  is  usually 
an  indication  of  involvement  of  the  pleura.  With  the  growth  of  the 
tumor,  the  blood-vessels  are  sometimes  compressed  in  such  a  way  as  to 
induce  turgescence  of  one  or  both  arms  and  lividity  of  the  face  and 
neck.  The  heart  may  be  displaced  toward  the  opposite  side,  and  the 
pneumogastric  and  recurrent  laryngeal  nerves  are  sometimes  pressed 
upon.  The  dyspnea  becomes  extreme  when  the  trachea  or  bronchi  are 
compressed  or  their  walls  invaded  by  the  growth.  The  subclavicular, 
axillary,  and  cervical  lymph-glands  are  often  enlarged.  Auscultation 
and  percussion  give  little  information  as  to  the  character  of  the  affec- 
tion and  are  of  value  chiefly  after  a  source  of  probable  metastatic 
infection  has  been  determined.  The  development  of  cachexia  is  one  of 
the  most  valuable  factors  in  diagnosis.  The  duration  of  the  disease 
after  its  recognition  is  generally  brief.  Death  has  occurred  as  early  as 
one  or  two  months  after  involvement  of  the  lung,  and  it  is  seldom 
delayed  longer  than  six  or  eight  months. 

The  prognosis  is  necessarily  fatal. 

The  treatmenf  is  palliative,  directed  to  the  relief  of  pain  and  the  sup- 
port of  strength.    Morphin  should  not  be  withheld. 


PARASITIC  DISEASES  OF  THE  LUNG. 

Echinococcus  of  the  lung  is  considered  on  page  286. 

Actinomycosis  of  the  Lung.— A  disease  caused  by  the  growth  within 
the  lung  of  the  actinomycosis,  or  ray  fungus.  This  may  result  either 
from  inhalation  of  the  fungus,  or  from  direct  extension  of  the  dis- 
ease from  the  jaw  and  neck.  Three  more  or  less  distinct  forms  are 
recognized,  as  noted  on  page  235,  one  affecting  particularly  the  bronchi 
another  producing  bronchopneum.onia,  and  a  third  resembling  tuber- 
culosis. The  inflammatory  process  tliat  is  set  up  is  usually  modified 
by  the  accompanying  pyogenic  bacteria.  With  manifestations  like  those 
of  an  intense  bronchitis  or  tuberculosis,  the  fibrous  tissue  of  the  lungs 
and  pleura  is  proliferated,  and  pus-pockets  are  often  formed  within  the 
new  tissue.  As  the  disease  progresses,  erosion  of  the  ribs  often  occurs 
and  the  skin  may  finally  be  perforated.  In  some  cases  the  perforation 
occurs  through  the  diaphragm,  and  the  pus  burrows  into  the  liver  or 
other  abdominal  organ,  or  it  may  pass  down  the  psoas  or  iliacus  muscle. 
The  disease  was  no  doubt  confounded  v/ith  tuberculosis  until  within  the 
past  few  years.  Septic  manifestations  are  common,  and  a  fatal  pyemia 
is  the  usual  termination.  The  extension  of  the  disease  outward  and 
the  perforation  of  the  skin  reveal  the  diagnosis,  since  the  fungus  can  be 
found  in  the  discharges.  This  also  distinguishes  the  disease  from  a 
syphilitic  or  tuberculous  abscess  with  fistulous  opening.  The  disease 
may  last  for  months  or  years,  during  which  time  metastatic  infections 
are  liable  to  occur,  with  the  production  of  abscesses  in  the  abdomi- 
nal organs,  heart,  and  brain.  The  patient  finally  succumbs  to  exhaus- 
tion. 

Treatmenf.— The  treatment  which  promises  most  is  the  administra- 


PLEURISY  417 

tion  of  large  doses  of  potassium  iodid.  Arsenic  or  iron  may  be  advan- 
tageously combined  with  it.  The  declining  strength  of  the  patient  calls 
for  the  most  nutritious  food  and  the  free  administration  of  alcohol  or 
strychnin. 

DISEASES  OF  THE  PLEURA. 
ACUTE  PLEURISY. 

Pleurisy  is  classified  :  (^)  Etiologically  as  primary  or  secondary;  (^) 
anatomically,  as  plastic  or  adhesive  (dry),  and  pleurisy  with  effusion; 
(^)  in  its  course,  as  acute  and  chronic ;  (^)  in  the  character  of  the  exu- 
date, as  fibrinous,  serofibrinous,  purulent,  and  hemorrhagic,  to  which 
is  sometimes  added  the  so-called  chylous  pleurisy.  (^)  In  addition  to 
these,  such  terms  as  diaphragmatic,  encysted,  interlobular,  and  tuber- 
cular are  often  employed  to  describe  differences  in  the  location  or  origin 
of  the  process. 

Fibrinous  Pleurisy. — Etiology. — The  disease  may  be  primary  or  sec- 
ondary in  origin,  (i)  Primary  pleurisy  is  often  attributed  to  cold,  but 
such  micro-organisms  as  the  bacillus  tuberculosis,  pneumococcus,  and 
streptococci  are  often  found,  and  are  then  looked  upon  as  the  exciting 
causes  of  the  inflammation. 

(2)  Secondary  pleurisy  generally  occurs  in  connection  with  acute  in- 
flammatory affections  of  the  lung.  It  is  constantly  present  in  acute 
pneumonia  and  it  is  generally  associated  with  abscess,  gangrene, 
hemorrhagic  infarction,  and  tuberculosis.  It  sometimes  results  from 
extension  of  inflammation  from  the  pericardium  or  other  adjacent  struc- 
tures. It  is  generally  encountered  in  penetrating  wounds,  malignant  or 
other  disease  of  the  wall  of  the  thorax,  and  caries  of  the  vertebrae. 

Morbid  Anatomy. — The  lesions  are  generally  unilateral.  The  pleura 
is  at  first  hyperemic  and  edematous.  The  surface  is  opaque  and  dry, 
and  a  layer  of  fibrin  of  variable  thickness,  uniform  and  smooth,  or 
with  a  granular  surface,  or  superimposed  layers  of  fibrin,  are  formed 
upon  the  surface.  Within  the  meshes  of  fibrin  are  leucocytes  and  often 
a  few  red  blood-corpuscles;  a  small  quantity  of  serum  is  also  exuded. 
Beginning  on  either  surface,  more  commonly  on  the  pulmonary,  the 
process  usually  extends  to  the  opposing  layer.  In  the  course  of  a  few 
days,  as  a  rule,  the  exudate  becomes  absorbed  and  adhesions  are  generally 
formed  between  the  two  layers  of  the  pleura.  These  are  often  perma- 
nent, particularly  when  the  apex  has  been  the  seat  of  the  disease. 

Symptoms. — The  disease  often  begins  with  a  sharp  stitch  in  the 
side,  which  is  aggravated  by  deep  breathing  and  coughing.  The  pain  is 
generally  referred  to  the  lo.wer  portion  of  the  chest,  but  it  may  be  con- 
fined to  the  apex  region.  A  dry  cough  is  usually  present.  In  the  more 
severe  cases  there  may  be  an  initial  chill,  with  slight  elevation  of  tem- 
perature. Tenderness  is  sometimes  elicited  by  pressure  over  the  affected 
region.  The  only  physical  sign  belonging  to  the  disease  is  a  dry  friction 
sound,  a  rubbing  to  and  fro  with  the  movements  of  inspiration  and 
expiration,  which  gives  the  impression  of  being  immediately  under 
the  ear.  It  is  usually  compared  to  the  creaking  of  new  leather. 
Sometimes  there  is  a  fine  dry,  crackling  sound  that  can  hardly  be  dis- 
tinguished from  the  crepitant  rale  of  lobar  pneumonia,  but  it  is  not 
27 


41 8  PRACTICE  OF  MEDICINE 

always  confined  to  the  end  of  inspiration,  as  in  that  disease.  Many 
other  rales  are  sometimes  heard  as  a  result  of  associated  inflammatory 
conditions  in  the  lung.  The  disease  often  occurs  at  longer  or  shorter 
intervals,  especially  when  it  is  tuberculous  in  origin. 

Serofibrinous  Pleurisy. — This  is  by  far  the  most  frequent  form  of  the 
disease;  it  is  the  form  commonly  known  as  pleurisy  with  effusion. 

Etiology. — The  causes  are  the  same  as  those  of  fibrinous  pleurisy. 
Bacteria  are  believed  to  play  even  a  more  important  part  in  its  pro- 
duction, and  a  great  many  cases  are  tuberculous.  The  disease  sometimes 
occurs  as  a  terminal  affection  in  hepatic  cirrhosis,  chronic  nephritis, 
and  cancer,  but  it  has  been  repeatedly  found  to  be  tubercular  in  these 
cases,  and  a  dropsical  effusion  is  more  commonly  formed.  Some  writers 
have  gone  so  far  as  to  attribute  all  cases  of  primary  pleurisy  with 
effuson  to  tubercular  infection.  But  the  pneumococcus  and  streptococcus 
are  without  doubt  the  exciting  factors  in  some  cases,  and  the  typhoid 
bacillus,  Friedlander's  bacillus,  and  the  diphtheria  bacillus  have  been 
found  in  some  instances.  The  tubercular  exudate  is  generally  sterile, 
but  that  from  the  streptococcus  or  pneumococcus  is  prone  to  become 
purulent. 

Morbid  Anatomy. — The  membrane  is  inflamed  and  covered  with  a 
layer  of  fibrin,  as  in  the  adhesive  form  of  the  disease,  but  the  serous  exu- 
date is  much  more  profuse,  so  that  an  accumulation  amounting  to  from 
one  to  four  quarts  (liters)  is  found  in  the  pleural  cavity.  This  is  usually 
a  clear  or  slightly  turbid,  straw-colored  serum,  containing  flocculi  of 
fibrin,  which  sometimes  settle  to  the  dependent  part  of  the  sac.  It  has 
a  specific  gravity  of  i.oio  to  1.015,  and  faintly  alkaline  reaction.  It 
is  highly  albuminous  and  usually  contains,  in  addition  to  fibrin,  a  great 
number  of  leucocytes  and  degenerated  epithelial  cells,  sometimes  a  itw 
red  blood-corpuscles.  It  rarely  coagulates  spontaneously.  Sugar,  uric 
acid,  and  cholesterin  are  sometimes  found  in  it.  The  lung  of  the  affected 
side  is  compressed  to  the  extent  required  to  accommodate  the  fluid. 
In  extreme  cases  the  entire  lung  is  pushed  back  against  the  upper  pos- 
terior wall  of  the  thorax  and  completely  collapsed.  In  such  cases  the 
mediastinum  with  the  heart  is  pushed  over  a  variable  distance  to  the 
opposite  side.  When  the  left  side  is  greatly  distended  with  fluid,  the 
apex  of  the  heart  may  reach  the  middle  line  of  the  sternum. 

Symptoms.— The  disease  sometimes  develops  abruptly  with  a  chill, 
severe  pain  in  the  side,  elevation  of  temperature,  and  a  dry  cough,  sug- 
gesting acute  pneumonia,  but,  as  a  rule,  it  is  less  severe  in  all  its  features. 
A  great  many  cases,  on  the  other  hand,  begin  so  insidiously,  with  little 
disturbance  beyond  a  gradually  increasing  dyspnea,  that  the  condition 
is  not  recognized  until  a  large  quantity  of  serum  has  accumulated. 
Dyspnea  is  usually  an  early  symptom.  It  is  at  first  due  to  the  pain 
and  in  a  measure  to  the  fever,  but  later  to  the  compression  of  the  lung 
by  the  fluid  accumulation.  When,  however,  the  accumulation  forms 
very  slowly,  there  is  often  but  little  evidence  of  dyspnea  except  on 
exertion.  The  pain,  at  first  sharp  and  severe,  is  generally  referred  to 
the  affected  area,  but  sometimes  to  the  back  or  abdomen.  The  fever 
seldom  exceeds  io3°F.  (39.5°C.)  and  it  is  often  intermittent  in  charac- 
ter. It  may  terminate  at  the  end  of  a  week,  or  it  may  persist  for  sev- 
eral weeks.    The  surface  temperature  is  higher  on  the  affected  side. 


PLEURISY  419 

Physical  Signs.— Inspection.— The  respiratory  movements  of  the  af- 
fected side  are  restricted  to  a  degree  that  corresponds  to  the  quantity 
of  effusion.  When  this  is  extreme,  it  even  causes  that  side  of  the  chest 
to  appear  as  if  it  were  in  a  constant  state  of  inspiratory  expansion. 
The  diameter  is  greater  than  that  of  the  unaffected  side,  but  the  differ- 
ence is  less  than  it  appears.  The  intercostal  furrows  are  obliterated 
and  may  rarely  become  slightly  prominent.  The  cardiac  impulse  is 
obliterated  or  displaced.  In  a  right-sized  effusion,  the  apex-beat  may 
be  displaced  beyond  the  left  nipple,  even  into  the  axilla  and  raised  to 
the  level  of  the  fourth  interspace.  In  left-sided  effusion,  the  apex  beat  is 
generally  concealed  behind  the  sternum.  The  pulsation  of  the  right  side 
of  the  heart  may  be  seen  at  the  right  of  the  sternum  and  perhaps 
as  high  as  the  third  or  fourth  interspace. 

Palpation. — The  affected  side  is  almost  immobile,  showing  little  or  no 
expansion  during  full  inspiration.  The  interspaces  feel  prominent.  The 
tactile  fremitus  is  diminished  when  the  accumulation  is  moderate,  and 
obliterated  when  it  is  excessive. 

Mensuration. — Differential  measurements  show  a  difference  of  from  a 
half-inch  to  more  than  an  inch  (i — 2.5  mm.)  between  the  two  sides 
when  at  rest.     The  measurements  may  be  about  equal  in  full  expansion. 

Percussion. — The  percussion  note  over  the  fluid  is  flat;  over  the  com- 
pressed lung  it  is  tympanitic,  the  tone  fading  away  into  complete  flat- 
ness as  the  lung  becomes  more  and  more  compressed.  Several  points 
should  be  carefully  studied  in  this  connection  :  ( i )  Percussion  over 
fluid  gives  a  very  different  sensation  to  the  fingers  than  that  obtained 
by  percussion  over  solidified  lung  tissue. 

(2)  The  upper  boundary  of  the  pleuritic  fluid,  when  the  patient  is  in 
the  erect  posture,  does  not  follow  a  horizontal  line,  but  a  curve  known 
as  the  Ellis  or  S-line  of  flatness.  When  the  quantity  of  fluid  is  moderate, 
the  lowest  point  is  behind,  near  the  spine.  From  that  point  it  advances 
upward  and  forward  in  an  S-curve  to  the  axillary  region,  and  thence 
declines  in  a  straight  line  to  the  sternum.  When  the  quantity  of  fluid 
is  extreme,  the  upper  margin  behind  is  concave ;  it  may  reach  the  clav- 
icle in  front  and  extend  beyond  the  sternum  of  the  healthy  side.  In 
order  to  determine  with  exactness  the  upper  boundary  of  the  fluid,  it  is 
necessary  to  percuss  with  a  light,  quick  stroke. 

(3)  A  peculiar  tympanitic  note,  known  as  Skoda's  resonance,  is  often 
heard  on  percussion  in  the  infraclavicular  region,  and  sometimes  in  the 
back  just  above  the  upper  margin  of  the  fluid. 

(4)  The  upper  margin  of  the  fluid  in  cases  of  moderate  accumulation 
is  found  to  change  when  the  position  of  the  patient  is  changed.  If  the 
upper  margin  of  the  fluid  be  marked  in  the  axillary  region  when  the 
patient  is  in  the  erect  posture,  the  previously  dull  area  will  be  found  to 
be  resonant  when  he  lies  upon  the  unaffected  side. 

Atiscultatio?i. — In  the  beginning,  when  the  exudation  is  but  slight,  a 
friction  sound  is  heard  with  the  respiratory  movements,  a  dry  crackling, 
as  in  the  fibrinous  form  of  the  disease;  but  as  soon  as  the  pleural  sur- 
faces have  been  separated  by  the  fluid  accumulation,  the  friction  dis- 
appears. When  the  accumulation  is  sufhcient  to  compress  the  lung,  the 
respiratory  sounds  become  less  distinct  and  apparently  distant.  With 
the  filling  of  the  chest,  the  sounds  undergo  many  changes;  sometimes 


42  o  PRACTICE  OF  MEDICINE 

there  is  tubular  breathing  with  distinct  inspiration  and  expiration, 
sometimes  only  a  short,  puffing  expiratory  sound;  sometimes  there  is 
a  metallic  quality  like  the  amphoric  breathing  heard  over  a  cavity. 
Numerous  rales  may  be  heard  as  adventitious  sounds,  when  tuberculosis, 
bronchitis,  or  other  disease  is  associated  with  the  pleurisy.  The  vocal 
sounds  are  also  modified,  absent,  or  intensified.  Much  depends  upon 
the  quantity  of  fluid,  the  position  of  the  patient,  and  the  presence  or 
absence  of  adhesions.  Bronchophony  is  not  infrequently  heard,  and 
occasionally  there  is  a  more  or  less  typical  egophony.  Baccelli  affirms 
that  the  whispered  voice  can  be  heard  through  a  serous  effusion,  but  not 
through  a  purulent  one,  but  exceptions  to  this  rule  have  been  repeatedly 
noted.  The  heart-sounds  may  be  normal,  but  a  systolic  murmur  is 
sometimes  heard  over  a  displaced  heart,  and  a  pleuropericardial  friction 
sound  is  not  unusual. 

As  the  fluid  undergoes  resorption,  the  respiratory  sounds  return. 
When  the  roughened  pleural  surfaces  again  come  into  contact,  there  is 
usually  produced  a  friction  sound  not  unlike  that  of  the  inflammatory 
stage,  sometimes  a  creaking  or  crackling,  sometimes  much  like  fine 
rales,  but  generally  described  as  a  redux  friction.  These  sounds  often 
persist  for  months,  or  recur  at  intervals  even  for  years,  especially  when 
there  is  a  tubercular  background.  The  heart-sounds  also  return  to 
their  normal  position  with  the  disappearance  of  the  fluid. 

The  duration  and  course  of  an  acute  serofibrinous  pleursy  are  very 
indefinite.  As  in  the  adhesive  form,  all  evidence  of  disease  may  subside 
within  a  week  or  ten  days;  a  moderate  exudate  is  sometimes  absorbed 
within  two  or  three  days.  When,  however,  the  fluid  has  become  excessive, 
compressing  the  lung,  it  is  more  apt  to  prove  persistent,  and  in  the 
tubercular  form  it  often  undergoes  little  change  in  quantity  for  many 
months.  While  the  natural  tendency  of  the  serofibrinous  exudate  is 
toward  absorption,  there  is  always  a  liability  to  the  development  of 
suppuration.  Spontaneous  evacuation  through  the  lung  or  chest-wall 
occasionally  occurs,  but  less  frequently  than  in  the  suppurative  form. 
Sudden  death  has  occurred  in  cases  of  long  standing,  usually  in  syncope, 
following  some  slight  exertion  or  a  sudden  change  of  position.  The 
exact  cause  of  the  accident  cannot  always  be  determined,  but  it  has 
been  attributed,  as  a  rule,  to  embolism  or  thrombosis  of  the  heart  or 
pulmonary  artery,  or  to  a  supposed  twist  of  the  great  vessels. 

PURULENT  PLEURISY. 

EMPYEMA. 

Eiioiogy.—(ia)  In  a  majority  of  instances  purulent  pleurisy  follows 
the  serofibrinous  form  of  the  disease,  but  it  is  often  primarily  purulent 
in  children.  Although  it  is  probably  of  bacterial  origin  in  most  cases, 
the  pus  is  often  found  to  be  sterile,  and  no  satisfactory  explanation 
of  its  occurrence  can  be  given  at  the  time.  Q^  It  often  develops 
after  the  acute  infections,  particularly  scarlet  fever,  pyemia,  som.etimes 
after  dysentery,  and  it  may  be  apparently  purulent  from  the  beginning. 
The  same  is  true  of  its  occurrence  with  typhoid  fever,  but  it  occurs  less 
frequently  in  that  connection.    An  important  relation  often  exists  between 


PLEURISY  421 

the  disease  and  pneumonia,  the  purulent  accumulation  developing  either 
during  the  pneumonic  attack  or  in  convalescence.  Aspiration,  done  with 
proper  precautions  for  the  prevention  of  septic  infection,  has  probably 
no  influence  in  the  conversion  of  a  serous  into  a  purulent  effusion.  In 
tuberculous  cases,  however,  the  needle  wound  may  be  sufficient  to  produce 
infection  under  the  most  careful  supervision,  the  infectious  matter  being 
derived  from  within,  (^c^  The  rupture  of  a  tubercular  cavity  in  the 
lung,  and  the  extension  of  malignant  disease  from  the  lung,  esophagus, 
or  thoracic  wall,  excites  a  purulent  pleurisy  in  some  cases.  (^)  The 
disease  may  be  established  also  as  a  result  of  injury,  a  penetrating 
wound,  or  the  fracture  of  a  rib. 

The  micro-organisms  most  frequently  found  in  the  exudate  are  the 
streptococcus,  staphylococcus,  especially  in  pyemic  cases;  the  pneumo- 
coccus,  usually  indicating  a  favorable  termination ;  the  micrococcus  lan- 
ceolatus;  and  the  tubercle  bacillus.  Most  cases  of  sterile  purulent  exu- 
dation are  tubercular.  The  leptothrix  pulmonus  has  been  found  in 
putrid  exudates,  and  psorosperms  have  been  discovered  in  a  few  cases. 

Morbid  Anatomy. — The  fluid  found  in  the  pleural  cavity  after  death 
varies  from  a  slightly  turbid,  seropurulent,  flocculent  liquid  to  a  thick, 
creamy  pus.  In  pneumococcous  cases  it  is  usually  thick  and  creamy  and 
has  only  a  faint,  sweetish  odor.  In  cases  associated  with  gangrene  it 
may  be  more  fluid  and  has  an  extremely  fetid  odor.  The  pleura  is  much 
thickened  and  is  often  eroded,  sometimes  perforated,  in  one  or  more 
places.  The  lung  may  be  much  compressed,  as  in  a  serofibrinous  ac- 
cumulation. 

Symptoms. — A  purulent  pleurisy  often  develops  so  insidiously  that 
it  can  be  regarded  as  of  rather  long  standing  when  discovered.  Symp- 
toms of  sepsis  sometimes  precede  its  recognition;  they  are  seldom  en- 
tirely absent.  Sometimes,  on  the  other  hand,  the  onset  is  abrupt.  The 
transition  from  a  serous  to  a  purulent  eff'usion  is  marked  in  some  cases 
by  a  rigor  with  rapid  and  pronounced  elevation  of  temperature  and  pro- 
found prostration,  often  accompanied  with  severe  pain  in  the  side,  which 
is  aggravated  by  deep  breathing.  Cough  is  generally  present,  but  it  is 
by  no  means  constant.  Dyspnea  is  more  uniformly  present,  but  it  may 
also  be  comparatively  slight  or  entirely  absent,  except  as  a  result  of 
exertion.  The  patient  sometimes  sinks  into  a  typhoid  state  soon  after 
the  development  of  pus,  and  more  certainly  after  the  exudate  has  be- 
come putrid.  The  course  of  the  disease  in  the  more  severe  cases  is 
marked  chiefly  by  manifestations  of  sepsis,  with  repeated  chills,  irregular 
or  intermittent  fever,  profuse  sweating,  and  finally  delirium.  Leucocyto- 
sis  is  present  and  often  reaches  a  high  grade.  Peptonuria  is  observed 
in  most  cases,  and  indicanuria  is  more  or  less  constant. 

Physical  Signs. — All  the  signs  characteristic  of  serofibrinous  pleu- 
risy are  found  in  the  purulent  form  of  the  disease.  In  addition  to  these, 
however,  certain  peculiarities  may  be  noted,  (^a)  The  distention  of  the 
chest  often  reaches  a  more  extreme  degree,  especially  in  children,  and  a 
bulging  of  the  intercostal  spaces  is  more  frequently  observed.  (^) 
The  heart  becomes  even  more  widely  displaced,  and  the  liver  and  spleen 
are  more  distinctly  depressed.  (<;)  The  subcutaneous  veins  are  often 
distended  over  the  affected  side,  and  the  chest-wall  may  become  edema- 
tous.    (^)  Fluctuation  has  been  noted,  but  generally  as  a  result  of  a 


42  2  PRACTICE  OF  MEDICINE 

beginning  process  of  spontaneous  evacuation  and  only  over  the  region 
of  "pointing."  (^)  The  vocal  sounds,  sometimes  audible  over  a  serous 
accumulation  (Baccelli's  sign),  are  not  transmitted  through  the  purulent 
exudate.  (/)  In  some  cases  a  peculiar  pulsation  can  be  detected  which 
is  synchronous  with  the  heart-beats  (pulsating  pleurisy).  It  is  due 
probably  to  nothing  more  than  the  forcible  action  of  the  heart  and  the 
weakened  resistance  of  the  chest-walls. 

The  natural  tendency  of  an  empyema  is  to  become  chronic  and, 
ultimately,  to  a  fatal  termination.  Spontaneous  recovery  has  been 
observed,  however,  in  a  few  instances,  either  through  absorption  of  the 
fluid  or  after  spontaneous  evacuation  through  the  lung  or  chest-wall. 
Evacuation  through  the  lung,  if  too  rapid,  may  terminate  fatally,  by 
suffocation,  the  large  quantity  of  pus  rapidly  filling  the  lung.  It  is 
only  in  cases  in  which  the  pus  seems  to  filter  through  an  area  of 
softened  lung  tissue  that  this  accident  is  prevented.  Spontaneous  evacu- 
ation through  the  chest-wall  (empyema  necessitatis)  usually  occurs  at 
some  point  in  the  anterior  wall  between  the  third  and  sixth  interspaces. 
More  than  one  opening  may  occur,  and  there  is  sometimes  a  fistulous 
tract  of  considerable  length  in  the  thoracic  wall.  Ultimate  recovery  is 
sometimes  observed  after  a  chronic  discharge  of  many  years'  duration. 
There  is  always  danger  in  these  cases,  however,  from  the  possible  pro- 
duction of  amyloid  disease.  Perforation  may  occur  also  into  the  esopha- 
gus, stomach,  pericardium,  or  peritoneum.  Cases  have  been  observed 
in  which  the  pus  passed  down  along  the  spine  and  psoas  muscle  to  the 
iliac  fossa,  producing  a  condition  resembling  a  psoas  or  lumbar  abscess. 

Special  Forms  of  Pleurisy.— i.  Tubercular  Pleurisy.— Many  writers 
regard  all  cases  of  pleurisy  with  eff"usion  as  of  tubercular  origin.  The 
clinical  manifestations  are  the  same  as  have  been  described,  and  need 
not  therefore  be  repeated.  From  the  standpoint  of  tuberculosis  the  con- 
dition has  been  considered  in  the  chapter  on  Tuberculosis. 

2,  Hemorrhagic  Pleurisy. — This  term  has  been  applied  to  cases  in 
which  the  serofibrinous  exudate  contains  blood  in  sufficient  quantity 
to  give  it  a  reddish  color.  The  condition  is  distinct  from  that  already 
described  under  the  head  of  Hematothorax.  Hemorrhagic  pleurisy  is 
encountered,  for  the  most  part,  in  :  (<?)  Tubercular  pleurisy,  from  the 
rupture  of  newly  formed  blood-vessels  in  the  exudate;  it  may  occur, 
however,  in  chronic  tuberculosis;  (^b^  in  cancer  of  the  pleura;  (r)  in 
asthenic  conditions  of  the  system,  resulting  from  cancer,  chronic  nephritis, 
hepatic  cirrhosis,  and  sometimes  in  the  malignant  types  of  infectious 
disease.  (</)  Cases  of  hemorrhagic  pleurisy  are  sometimes  met  with 
in  persons  previously  healthy  and  in  whom  its  occurrence  cannot  be 
explained.  It  should  not  be  forgotten  that  a  clear  serous  effusion  may 
become  contaminated  with  blood  as  a  result  of  the  injury  of  a  small 
vessel  in  aspiration. 

3.  Encysted  Pleurisy.— The  pleuritic  effusion  is  sometimes  circum- 
scribed by  adhesions  to  such  an  extent  as  to  separate  it  from  the  gen- 
eral pleural  cavity,  or  two  or  more  pockets,  loculi,  may  be  formed. 
These  may  be  separated  or  they  may  communicate  through  small 
openings.  The  pockets  may  be  found  in  any  part  of  the  pleural  cavity, 
as  on  the  sides,  or  they  may  be  confined  to  the  diaphragmatic  surface. 
The  diagnosis  is  often  difficult,  but  a  friction  sound  is  sometimes  heard, 


PLEURISY  423 

and  the  aspirator  needle  withdraws  fluid  from  the  area  of  dullness.  The 
condition  is  more  frequent  in  connection  with  a  purulent  than  with  a 
serous  effusion. 

4.  Diaphragmatic  Pleurisy.— This  term  is  apphed  to  cases  in  which 
the  inflammation  is  limited,  in  part  at  least,  to  the  diaphragmatic 
pleura.  It  may  be  adhesive  or  serofibrinous.  The  effusion  is  not  great 
in  quantity,  as  a  rule.  Pain  is  the  most  prominent  feature;  it  is  gen- 
erally severe  and  confined  to  the  affected  region  and  limits  the  respira- 
tory movements.  It  sometimes  suggests  angina  pectoris,  or  it  may  be 
referred  to  the  epigastrium.  There  is  generally  tenderness  to  pressure 
over  the  diaphragm,  especially  over  its  insertion  to  the  tenth  rib  and 
extending  from  its  anterior  extremity  to  the  sternum  and  xiphoid 
cartilage. 

5.  Interlobular  Pleurisy.— Inflammation  of  the  interlobular  pleura 
usually  accompanies  pleurisy  of  other  regions.  It  is  more  frequent  on 
the  right  than  on  the  left  side,  and  most  marked  near  the  root  of  the 
lungs,  between  the  upper  and  middle  lobes.  As  a  result  of  it,  the  sur- 
faces are  closely  agglutinated,  but  in  some  instances  a  pocket  is  formed. 
The  exudate  may  be  serous  or  purulent,  and  tubercles  are  commonly 
to  be  found.  Spontaneous  evacuation  of  the  encysted  fluid  sometimes 
occurs  through  perforation  of  a  bronchus,  and  the  resulting  purulent 
expectoration  may  be  the  first  symptom  to  indicate  the  presence  of  a 
suppurative  process  within  the  chest.  In  some  cases,  however,  there  is 
a  history  of  previous  attacks  of  pleurisy. 

Diagnosis  of  Pleurisy. — An  adhesive  pleurisy  is  generally  recognized 
without  difficulty  by  its  symptoms  and  physical  signs.  In  pleurisy 
with  extensive  effusion,  too,  the  diagnosis  is  generally  simple.  The 
presence  of  fluid  and  its  character  can  be  immediately  demonstrated 
with  the  hypodermic  needle.  When,  however,  the  quantity  of  fluid  is 
moderate,  many  of  the  physical  signs  are  sometimes  wanting  or  they 
may  be  of  such  a  character  as  to  simulate  other  affections,  especially 
lobar  pneum^onia,  simple  hydrothorax,  or  excessive  pericardial  effusion. 
Echinococcus  cyst,  subphrenic  abscess,  and  tumors  of  the  base  of  the 
lung  may  be  excluded  in  some  cases. 

Pneumonia  is  generally  characterized  by  a  greater  severity  of  the  sub- 
jective manifestations ;  the  sudden  onset  with  chill,  the  high  temperature, 
greater  prostration,  together  with  the  physical  signs,  showing  bronchial 
breathing,  an  increase  rather  than  diminution  of  tactile  and  vocal  fremi- 
tus. In  pneumonia,  too,  the  boundary  of  dullness  is  usually  highest 
posteriorly,  corresponding  to  the  limit  of  the  interlobular  fissure,  while 
in  pleurisy  it  is  lowest  at  the  spine. 

Hydrothorax  is  a  dropsical  accumulation  of  fluid  within  the  chest. 
It  is  generally  bilateral,  is  not  attended  with  the  characteristic  stitch  in 
the  side,  but  develops  insidiously,  as  a  rule,  in  the  course  of  a  chronic 
disease  of  the  heart  or  kidneys,  or  in  hepatic  cirrhosis,  cancer,  or  other 
affections  which  lead  to  dropsy. 

Pericardial  Effusion. — It  is  only  when  the  pericardial  accumulation  is 
enormous  that  it  can  be  mistaken  for  a  pleuritic  effusion.  There  is  a 
sense  of  distress  rather  than  of  pain  in  the  precordial  region,  and  the 
dyspnea  is  extreme.  Percussion  reveals  a  circumscribed  area  of  flatness 
corresponding  in  outline  to  the  distended  pericardial  sac.    The  heart- 


424  PRACTICE  OF  MEDICINE 

sounds  are  not  displaced  to  the  right,  but  they  are  often  nearly  or 
quite  inaudible,  and  the  pulse  is  usually  feeble. 

Hydatid  cyst,  tumors  of  the  liver,  and  upward  displacement  of  the 
liver  cause  dullness  simulating  that  of  a  right-sided  pleuritic  effusion, 
often  reaching  the  fourth  rib  in  front  and  embarrassing  respiration. 
But  in  these  conditions  the  upper  margin  of  dullness  does  not  follow 
the  curving  line  of  pleuritic  effusion. 

Abscess  of  the  lung  may  lead  to  confusion  when  the  aspirator  needle  has 
been  thrust  into  the  pus-sac.  As  a  rule,  however,  the  symptoms  are  so 
different,  the  sudden  development  of  dyspnea  with  rapid  breathing,  and 
purulent  expectoration,  that  empyema  is  not  suggested. 

Treatment. — i.  Fain. — In  the  initial  stage  of  pleurisy  of  either  form, 
the  pain  may  be  so  severe  as  to  call  for  the  hypodermic  administration 
of  morphin.  It  may,  however,  yield  to  the  application  of  heat,  cold,'  or 
counter-irritation.  Much  benefit  is  derived  from  the  application  of  dry 
cups  or  leeches  over  the  affected  region ;  and  the  application  of  a  band 
or  adhesive  strip  around  the  chest  tightly  enough  to  restrict  the  re- 
spiratory movements  is  of  great  comfort  to  the  patient.  A  mercurial 
or  saline  purge  should  generally  be  given  at  the  onset. 

2.  77ie  Effusion. — When  a  serous  effusion  has  formed,  it  is  well  to  con- 
fine the  patient  to  bed  for  a  few  days  and  to  favor  the  resorption  of 
the  fluid  by  limiting  the  ingestion  of  fluids  and  confining  the  diet  to 
"dry"  food,  providing  there  be  no  fever.  Saline  cathartics  should  be 
given  in  concentrated  form.  Counter-irritation  with  mustard,  turpen- 
tine, or  iodin  seems  to  hasten  absorption  in  some  cases.  A  hot  vapor 
bath  acts  well,  and  free  diaphoresis  produced  by  pilocarpin  is  often  fol- 
lowed by  rapid  absorption  of  a  moderate  effusion.  Diuretics  are  some- 
times of  service. 

Paracentesis.— P^s^iration  should  be  resorted  to :  (^r)  As  soon  as  it 
becomes  apparent  that  these  methods  of  treatment  will  not  prove  effec- 
tive, (^)  whenever  the  accumulation  of  fluid  is  so  rapid  as  to  cause 
marked  dyspnea  or  (r)  when  the  effusion  becomes  considerable  and 
persists  for  several  days,  although  dyspnea  be  not  a  prominent  symp- 
tom. The  operation  is  so  simple  that  there  are  practically  no  contra- 
indications, for  the  fever  often  subsides  after  the  withdrawal  of  the  fluid. 
It  must  be  performed,  however,  under  the  strictest  measures  of  anti- 
sepsis, including  disinfection  of  the  skin  and  of  the  operator's  hands 
with  mercuric-chlorid  solution  and  thorough  cleansing  and  boiling  of 
the  needle.  The  instrument  should  always  be  tested  and  its  action 
should  be  thoroughly  understood  before  beginning  the  operation.  The 
point  selected  on  the  left  side  is  usually  either  the  seventh  intercostal 
space  in  the  axillary  line  or  the  eighth  immediately  below  the  angle  of 
the  scapula,  and  on  the  right  side  the  sixth  interspace  in  the  axillary 
line.  The  arm  of  the  patient  is  brought  forward  and  the  hand  allowed 
to  rest  on  the  opposite  shoulder,  to  widen  the  intercostal  spaces,  and  the 
needle  is  thrust  in  close  to  the  upper  margin  of  the  rib  in  order  to  avoid 
the  intercostal  artery.  The  skin  should  be  drawn  up  a  little  before  in- 
serting the  needle,  so  that  the  wound  will  be  drawn  dowm  over  the  rib 
after  the  needle  is  withdrawn.  Ethyl  chlorid  may  be  employed  to  deaden 
the  sensibility  of  the  skin,  but  it  is  not  usually  required  in  adults,  since 
it  is  not  necessary  to  use  a  large  needle.    The  fluid  should  be  withdrawn 


PLEURISY  425 

slowly.  The  quantity  to  be  withdrawn  depends  to  some  extent  upon  the 
quantity  of  the  efifusion,  the  age  and  physical  condition  of  the  patient. 
Some  writers  advocate  the  withdrawal  of  all  the  fluid  obtainable,  while 
others  Hmit  it  to  a  quart  (Hter)  or  even  a  pint  (5°°  c.c).  The  with- 
drawal of  a  small  quantity  sometimes  stimulates  the  absorption  of  the 
remainder.  The  operation  should  generally  be  repeated  at  intervals 
of  a  few  days,  as  long  as  the  effusion  continues  to  reaccumulate. 
Accidents  rarely  occur  in  paracentesis.  A  sharp  pain  is  generally  com- 
plained of  after  a  variable  quantity  of  fluid  has  been  withdrawn,  and  it 
may  persist  until  it  becomes  evident  that  the  aspiration  should  be  dis- 
continued. A  pneumothorax  has  been  produced  in  a  few  instances,  and 
a  cutaneous  emphysema  is  even  more  common.  An  albuminous  expecto- 
ration has  been  observed  after  the  tapping,  and  it  has  been  accompanied 
with  rapidly  fatal  dyspnea  in  a  few  instances.  Syncope  or  slight  faint- 
ness  is  not  uncommon,  and  epileptic  seizures  have  been  observed  in  a  few 
instances. 

3.  Empyema. — The  treatment  of  empyema  is  strictly  surgical.  With 
the  determination  of  the  purulent  character  of  the  fluid,  the  utility  of 
aspiration  ceases,  and  an  early  surgical  interference  becomes  imperative. 
The  operation  consists  of  making  a  free  incision  through  the  chest-wall, 
usually  with  exsection  of  a  portion  of  one  or  more  ribs,  and  the  estab- 
lishment of  free  drainage.  Irrigation  is  sometimes  necessary,  especially 
when  the  pus  is  found  to  be  fetid.  The  operation  is  so  simple  that  it 
is  applicable  to  all  cases  of  empyema,  regardless  of  the  condition  of  the 
patient,  and  it  aff'ords  the  surest  means  of  relief.  Cases  in  which  the  pneu- 
mococcus  is  found,  and  cases  aff"ecting  children,  should  not  be  excluded, 
for,  although  spontaneous  recovery  has  been  known  to  occur  in  them, 
complete  recovery  is  more  rapid  and  the  subsequent  expansion  of  the 
lung  more  certain  after  operation. 

CHRONIC  PLEURISY. 

Chronic  pleurisy  is  of  two  forms,  distinguished  by  the  presence  or 
absence  of  effusion,  and  known  as  (^)  the  adhesive  or  dry,  and  (J?^ 
chronic  pleurisy  with  effusion. 

Etiology. — The  disease  may  follow  either  form  of  acute  pleurisy,  but 
it  often  begins  insidiously  as  a  subacute  or  chronic  process.  The  influ- 
ences which  favor  its  development  are  the  same  as  those  of  acute  pleu- 
risy— cold,  wet,  tuberculosis,  and  other  conditions  producing  moderate 
inflammation  of  the  pleura. 

Morbid  Anafomy. — (^7)  Chronic  Adhesive  Pletirisy. — As  in  the  acute 
form  of  the  disease  the  lesions  are  usually  confined  to  one  side,  but 
both  pleurse  are  sometimes  affected.  The  changes  are  usually  most 
pronounced  near  the  base  of  the  lung,  unless  they  are  tubercular  in  origin, 
when  they  are  more  commonly  found  at  the  apex  and  often  on  both 
sides.  The  pleura  is  much  thickened  and  firm,  but  the  apparent  thick- 
ness is  much  increased,  especially  after  pleurisy  with  eff'usion,  by  the 
superimposed  layers  of  fibrin,  which  become  organized  and  firmly  adher- 
ent. It  is  often  impossible  to  separate  the  layers,  and  the  entire  thick- 
ness often  amounts  to  more  than  an  inch.  Contraction  of  this  new  con- 
nective tissue  causes  shrinking  and  deformity  of  the  affected  side  of  the 


426  PRACTICE  OF  MEDICINE 

thorax  in  old  cases.  Calcareous  degeneration  sometimes  occurs.  The 
underlying  lung  may  be  found  in  a  state  of  carnification  when  com- 
pressed by  fluid,  and  bronchiectatic  cavities  are  not  infrequently  found  in 
it.  In  some  cases  a  process  of  sclerosis  extends  from  the  thickened  pleura 
to  a  variable  distance  into  the  substance  of  the  lung,  involving  espe- 
cially the  interlobular  connective  tissue.  Villous  projections  from  the 
surface  have  also  been  observed. 

(<5)  Chronic  Pleurisy  with  Effusion. — The  pleura  is  much  thickened  and, 
as  a  rule,  covered  with  a  variable  thickness  of  more  or  less  completely 
organized  fibrin.  In  other  respects  the  condition  is  much  the  same  as 
that  of  the  acute  form  of  the  disease.  In  many  cases  a  greater  or  less 
number  of  pockets  are  found,  as  in  encysted  pleurisy.  In  purulent  cases 
of  long  standing  the  pus  may  be  thick  and  calcareous. 

Symptoms. — In  a  majority  of  cases  the  patient  suffers  from  periodical 
attacks  of  acute  pleurisy,  with  stitch  in  the  side  or  a  sense  of  dragging 
in  the  lower  part  of  the  chest.  The  general  health  may  be  but  little 
impaired,  and  many  cases  are  recognized  only  through  their  objective 
signs.  The  expansion  of  the  chest  may  be  much  restricted  on  the  affected 
side,  and  the  respiratory  and  vocal  sounds  diminished  or  suppressed. 
In  other  cases  there  are  marked  dullness  and  suppression  of  these  sounds 
without  much  impairment  of  respiratory  action.  In  cases  of  the  adhe- 
sive form,  after  the  fibrous  tissue  has  contracted,  a  corresponding  depres- 
sion of  the  chest-wall  is  produced.  The  respiratory  and  vocal  sounds 
are  diminished  and  distant,  on  account  of  the  thickening  of  the  pleura. 
Dyspnea  is  usually  brought  on  by  exertion,  and  the  patient  becomes 
weak  and  emaciated  as  the  disease  progresses. 

Diagnosis. — The  chronic  adhesive  form  is  often  difficult  of  recognition. 
Its  presence  may  be  inferred,  however,  from  the  dullness,  diminished 
vocal  resonance,  and  particularly  from  the  resistance  offered  by  the 
thickened,  indurated  pleura  to  the  passage  of  the  aspirator  needle. 
When  effusion  is  present,  it  can  be  demonstrated  by  aspiration.  The 
hypodermic  needle  is  generally  too  short  to  penetrate  beyond  the  thick 
layers  of  the  pleura. 

Prognosis. — The  disease  is  not  of  itself  fatal,  but  it  renders  the  pa- 
tient more  liable  to  other  pulmonary  affections — bronchiectasis,  bron- 
chitis, and  bronchopneumonia. 

Treatment— When  the  pain  is  severe,  the  case  should  be  treated  as 
one  of  acute  pleurisy.  The  contraction  of  the  chest  in  the  later  stages 
of  the  disease  may  be  overcome  to  some  extent  by  systematic  exercise 
of  the  respiratory  muscles  and  by  so-called  respiratory  gymnastics,  the 
patient  practicing  full  inspiration  and  forced  expiration  through  a  tube 
or  other  device  for  regulating  the  resistance.  The  general  condition  of 
the  patient  should  be  looked  after.  Tonics,  nutritious  food,  and  fresh 
air  are  indicated. 

HYDROTHORAX. 

Definition.— A  noninflammatory  accumulation  of  serous  fluid  in  the 
pleural  cavity. 

Etio/ogy.— The  condition  is  always  secondary  to  some  other  affection; 
it  is  a  symptom,  not  a  disease,  and  occurs  for  the  most  part  in  con- 
nection with  general  dropsy  in  the  course  of  cardiac  or  renal  disease  or 


PNEUMOTHORAX 


427 


affections  causing  a  hydremic  condition  of  the  blood.  The  accumulation 
generally  occurs  in  both  sides,  but  it  may  be  unilateral,  and  is  often 
more  copious  in  one  cavity  than  in  the  other.  It  sometimes  develops  as 
a  result  of  the  pressure  of  intrathoracic  or  mediastinal  neoplasms.  As  a 
terminal  affection  it  is  often  met  with  in  pulmonary  diseases  and  others 
terminating  in  cardiac  failure.  The  accumulation  is  often  rapid,  but 
seldom  so  extreme  as  that  of  serous  pleurisy.  There  is  no  pain  or  fever, 
as  a  rule.  The  lung  becomes  compressed,  and  a  corresponding  dyspnea 
is  produced. 

The  physical  signs  are  the  same  as  those  of  a  serofibrinous  pleurisy, 
but  the  heart  is  rarely  displaced.  The  diagnosis  is  readily  established 
by  the  introduction  of  the  hypodermic  needle.  The  prognosis  is  that  of 
the  causal  condition. 

Treatment. — It  is  only  when  the  dyspnea  becomes  urgent  that  treat- 
ment must  be  directed  to  the  hydrothorax.  The  fluid  may  be  with- 
drawn by  aspiration,  but  it  rapidly  reaccumulates.  The  treatment  of 
the  underlying  condition  is  of  more  importance,  embracing  the  various 
measures  for  the  removal  of  dropsical  effusions  in  cardiac  and  renal  dis- 
eases. 

PNEUMOTHORAX,   HYDROPNEUMOTHORAX,   PYOPNEU- 
MOTHORAX. 

Pneumothorax,  air  in  the  pleural  cavity,  is  an  exceedingly  rare  con- 
dition. Hydropneumothorax,  in  which  a  serous  effusion  occupies  a  part 
of  the  cavity,  and  pyopneumothorax,  in  which  pus  is  present,  are  more 
frequently  met  with. 

Etiology. — The  condition  is  more  frequent  in  adult  males  and  is  gen- 
erally a  result  of:  (d-)  Perforating  wounds,  whether  accidental  or  sur- 
gical. It  sometimes  follows  the  exploratory  puncture  of  a  hypodermic 
needle  and  more  certainly  incisions  for  the  evacuation  of  pus,  or  a  spon- 
taneous evacuation  of  an  empyema,  pulmonary  abscess,  or  hydatid  cyst 
through  the  chest-wall,  (Z')  Perforation  of  the  lung.  This  sometimes 
occurs  in  a  healthy  lung  as  a  result  of  violent  straining,  as  in  pertussis, 
parturition,  or  defecation,  or  blows  upon  the  chest ;  rarely  without  cause 
and  with  the  lung  at  rest.  In  such  cases  the  air  is  sometimes  absorbed, 
but,  as  a  rule,  pleuritic  inflammation  and  exudation  are  excited  by  it.  In 
a  majority  of  cases,  however,  the  perforation  of  the  lung  is  a  result  of 
disease,  as  the  caseous  softening  and  rupture  of  a  tubercular  focus,  septic 
bronchopneumonia,  or  gangrene,  rarely  from  the  breaking  down  of  a 
hemorrhagic  infarct.  The  perforation  may  occur  also  from  the  pleural 
side  in  an  old  empyema.  (<:)  Perforation  sometimes  occurs  through  the 
diaphragm  in  connection  with  gastric,  esophageal,  or  intestinal  ulceration, 
especially  that  due  to  malignant  disease.  In  these  conditions,  intestinal 
gases  are  found  instead  of  air.  Qtf)  The  condition  has  resulted  also  from 
the  passage  of  air  down  along  the  trachea  after  tracheotomy.  (^)  Gas  is 
very  rarely  developed  within  a  pleural  exudate  as  a  result  of  the  action 
of  bacteria,  notably  the  bacillus  aerogenes  capsulatus,  and  a  hydro- 
pneumothorax is  developed. 

The  air  enters,  or,  as  some  writers  express  it,  is  drawn  into,  the  pleural 
cavity  when  a  perforation  occurs,   on  account  of  the  elasticity  of  the 


42  8  PRACTICE  OF  MEDICINE 

lung,  which  causes  it  to  collapse.  This  elasticity  normally  creates  a  con- 
dition of  negative  pressure,  and  the  collapse  continues  until  this  pressure 
has  been  equalized  by  the  entering  air.  Owing  to  a  similar  elasticity  of 
the  opposite  lung  and  the  abdominal  viscera,  the  affected  pleural  sac 
becomes  distended,  the  heart  is  displaced  to  the  opposite  side,  and  the 
diaphragm  is  depressed.  Sometimes  when  the  abnormal  opening  be- 
comes closed,  the  internal  pressure  grows  even  greater  than  the  atmos- 
pheric, and  the  displacements  are  correspondingly  increased.  The  most 
pronounced  displacements  occur,  however,  when  the  opening  is  of  a  val- 
vular form,  which  permits  the  entrance  of  air,  but  prevents  its  exit. 

Morbid  Anatomy. — Post-mortem  examination  reveals,  in  addition  to 
the  accumulated  air  and  fluid  and  the  resulting  displacements  and  com- 
pression of  the  lung,  a  more  or  less  pronounced  hyperemia  of  the  pleura. 
The  abnormal  opening  is  often  discovered  with  difficulty  owing  to  its 
small  size. 

Symptoms. — When  the  disease  develops  in  connection  with  advanced 
pulmonary  disease,  and  usually  when  it  is  the  result  of  incision  for  the 
evacuation  of  an  empyema,  comparatively  little  disturbance  is  produced 
by  the  entrance  of  air  into  the  pleural  cavity.  As  soon  as  the  internal 
pressure  has  become  equal  to  the  external  after  incision,  the  air  passes 
in  and  out,  producing  a  hissing  sound,  with  the  respiratory  movements. 
Latent  cases  are  sometimes  discovered  at  autopsy.  When,  however,  it 
develops  after  a  sudden  perforation  of  the  lung  or  chest-wall,  a  sharp 
pain  is  generally  complained  of  with  intense  dyspnea,  cough,  cyanosis, 
and  rapid  respiration,  often  amounting  to  50  or  more  in  the  minute. 
The  pulse  becomes  rapid  and  feeble,  and  the  patient  may  sink  into  a 
collapse,  with  cold  perspiration  and  subnormal  temperature.  Death 
occasionally  results  from  shock.  If  the  condition  lasts  for  a  few  days, 
and  particularly  if  pyothorax  be  also  present,  fever  of  a  hectic  type 
generally  develops  as  a  result  of  the  pleuritic  inflammation  which  is 
excited.  The  hand  of  the  affected  side  has  been  found  edematous  in 
exceptional  cases. 

Physical  Signs. — Inspection. — The  affected  side  is  greatly  distended  and 
immobile;   and  the  opposite  side  is  similarly,  though  less,  affected. 

Palpatio7i. — The  tactile  fremitus  is  diminished  over  the  upper,  air- 
containing  portion  of  the  chest,  and  nearly  or  quite  absent  over  the 
lower  portion  when  fluid  is  present.  The  apex  beat  of  the  heart  is  indis- 
tinct and  displaced  toward  the  opposite  side. 

Percussion. — The  resonance  may  be  high-pitched,  ringing,  tympanitic 
in  quality,  amphoric,  or  of  a  low  pitch  approaching  closely  to  dullness. 
Dullness  has  been  noted,  in  fact,  in  some  instances.  The  lower  portion 
of  the  chest  generally  yields  a  flat  note  owing  to  the  presence  of  fluid. 
This  dullness  changes,  however,  with  the  position  of  the  patient,  as  in  a 
case  of  moderate  pleuritic  effusion,  and  usually  to  a  more  marked 
degree.  The  cracked-pot  sound  can  be  obtained  in  some  cases  in  which 
there  is  a  large  external  opening. 

Aiisctiltation. — Over  the  compressed  lung  the  respiratory  sounds  are 
feeble  and  distant  or  quite  inaudible.  Moist  rales  are  often  heard,  and 
the  metallic  tinkle  of  Laennec  is  sometimes  present.  Succussion  may 
sometimes  be  obtained  by  shaking  the  patient  from  side  to  side,  and  it 
is  sometimes  audible  a  short  distance  from  the  chest.    The  voice-sounds 


PNEUMOTHORAX  429 

are  high-pitched  and  metalUc,  but  usually  faint.  One  of  the  most  valu- 
able signs  is  that  known  as  the  coin  test,  in  which  a  metallic  sound 
produced  by  striking  a  coin  placed  upon  the  anterior  chest-wall  with 
another  coin  is  transmitted  with  increased  intensity  to  the  ear  placed 
upon  the  posterior  wall. 

Diagnosis. — Pneumothorax  is  readily  recognized  by  its  physical  signs, 
especially  when  succussion  can  be  obtained.  When,  however,  the  per- 
cussion note  is  dull,  the  condition  is  easily  mistaken  for  one  of  ordinary 
effusion.  Error  may  arise  also  in  the  presence  of  a  dilated  stomach, 
diaphragmatic  hernia,  subphrenic  abscess  containing  air ;  and  the  encap- 
sulated form  must  be  distinguished  from  a  large  lung  cavity. 

In  pleuritic  effusion  tubular  breathing  is  heard  above  the  water-line, 
while  in  pneumothorax  the  respiratory  sound  is  usually  absent;  suc- 
cussion, the  metallic  tinkle,  and  the  coin  tests  are  absent. 

In  a  greatly  dilated  stomach,  succussion  can  be  produced,  and  there 
is  hyper-resonance  of  tympanitic  quality,  but  this  is  confined  to  the 
abdomen  and  lower  part  of  the  thorax,  and  the  respiratory  and  vocal 
signs  are  unaffected. 

Diaphragmatic  hernia  is  either  congenital  or  a  result  of  injury.  In 
it  the  tympanitic  note  is  confined  to  the  lower  zone  of  the  chest.  Bor- 
borygmi  are  generally  heard. 

Subphrenic  abscess  containing  air  is  rare.  It  is  confined  to  the  right 
side  and  can  be  mistaken  only  for  an  encysted  pyopneumothorax.  Pul- 
monary symptoms  are  absent;  the  heart  is  not  displaced;  there  is  usually 
a  history  of  preceding  gastric  or  intestinal  ulceration,  and  epigastric 
tenderness  is  found  on  palpation.  The  pus  flows  freely  when  the  aspi- 
rator needle  is  inserted. 

Prognosis. — The  result  depends  greatly  upon  the  cause  of  the  con- 
dition. Previously  healthy  individuals  often  recover,  but  chronic  tuber- 
culous patients  generally  succumb  within  from  a  few  days  to  two  weeks. 

Treatment — The  case  is  to  be  managed  for  the  most  part  as  one  of 
pleurisy  with  effusion.  When  dyspnea  develops,  the  fluid  should  be  with- 
drawn by  aspiration,  or,  if  the  accumulation  be  purulent,  a  permanent 
opening  should  be  made  for  its  evacuation.  Respiratory  gymnastics 
should  be  practiced  when  there  is  a  chance  for  recovery. 


SECTION  VI. 
Diseases  of  the  Digestive  System. 


DISEASES  OF  THE  MOUTH, 


STOMATITIS. 

Catarrhal  stomatitis  (simple  or  erythematous  stomatitis)  is  the 
most  frequent  affection  of  the  mouth.  It  is  caused  by  mechanical,  chem- 
ical, thermal,  or  bacterial  irritants,  (i)  It  is  quite  common  in  im- 
properly fed  and  poorly  nourished  infants,  and  may  be  associated  with 
gastrointestinal  disturbance  or  the  irruption  of  the  teeth.  (2)  In 
adults  it  may  be  primary  or  secondary.  («)  It  often  results  from  the 
use  of  tobacco,  the  chewing  of  spices,  from  hot  food  or  drink,  acids  or 
alkalis,  or  from  injury  by  sharp  foreign  bodies  or  carious  teeth.  (^) 
It  may  accompany  indigestion,  and  occurs  in  the  course  of  the  acute 
fevers.  It  is  occasionally  an  extension  from  disease  of  the  pharynx  or 
tonsils. 

Symptoms. — The  affected  mucous  membrane  is  at  first  swollen,  dry, 
red,  and  painful;  later  it  becomes  moist,  for  the  secretion  becomes  ex- 
cessive. The  condition  may  be  limited  to  one  or  more  small  areas  or 
involve  the  entire  surface  of  the  mouth  and  tongue.  The  tongue  is 
usually  furred,  often  indented  by  the  teeth,  and  its  papillae  are  enlarged. 
There  is  extreme  thirst,  and  in  children  the  temperature  may  be  moder- 
ately elevated.  A  disagreeable  taste  is  complained  of.  The  saliva  con- 
tains desquamated,  degenerated  epithelium,  bacteria,  and  debris  of  food. 
The  disease  does  not  usually  last  longer  than  5  to  7  days. 

Treatment — The  treatment  consists  in  cleansing  the  mouth,  especially 
after  eating,  with  an  alkaline  solution,  borax  in  glycerin  and  rose-water, 
or  a  solution  of  boric  acid,  applied  with  a  cotton  swab.  In  adults  a  i 
per  cent  solution  of  carbolic  acid  or  i  :  i  o  of  hydrogen  peroxid  may  be 
employed.  These  failing,  a  0.5  to  i  per  cent  solution  of  silver  nitrate 
should  be  applied.  The  cause,  if  recognized,  should  be  removed.  Only 
liquid  food  should  be  allowed. 

Aphthous  Stomatitis  (Follicular  or  Vesicular  Stomatitis).— A  form 
of  catarrhal  stomatitis  in  which  small  vesicles  form,  especially  upon  the 
mucous  membrane  of  the  lips,  cheeks,  and  ledges  of  the  tongue,  occasion- 
ally on  the  pillars  and  pharynx.  These  rupture  in  the  course  of  24 
hours  and  leave  ulcers  surrounded  by  a  zone  of  hyperemia.  Successive 
crops  sometimes  develop. 

Etiology.— Tht  affection  is  commonest  from  the  first  to  the  fourth 
year,  but  may  occur  in  adults.  It  is  probably  due  to  the  action  of  bac- 
teria, but  no  specific  microbe  has  been  identified  with  it.  The  affection 
develops    in    connection  with  protracted  gastrointestinal  disturbances, 


STOMATITIS  431 

improper  feeding,  malnutrition,  anemia,  and  the  infectious  diseases,  par- 
ticularly tuberculosis. 

Symptoms. — Vesicles  and  ulcers  occur,  singly  or  in  clusters  of  a  dozen 
or  more,  and  they  may  coalesce,  especially  when  they  accompany  an 
infectious  disease.  The  area  is  surrounded  by  a  zone  of  catarrhal  stoma- 
titis. The  ulcers  are  so  sensitive  and  painful  that  the  child  often  refuses 
to  nurse  and  becomes  restless  and  fretful.  When  the  pharynx  is  involved^ 
deglutition  is  painful.  The  secretion  of  the  mouth  is  increased,  and  driv- 
eling is  produced.  The  breath  may  be  offensive,  but  not  fetid.  There 
are  usually  no  constitutional  symptoms  beyond  those  of  the  accompany- 
ing disease. 

Treatment. — Each  ulcer  should  be  touched  with  silver  nitrate  fused 
upon  a  probe,  after  a  careful  application  of  cocain  (2  percent).  Appli- 
cation of  a  solution  of  borax  in  glycerin  and  water,  potassium  chlorate, 
or  hydrogen  peroxid  is  beneficial.  The  constitutional  condition  should 
be  treated.  The  disease  generally  subsides  promptly  upon  recovery  from 
the  causal  affection. 

The  aphthcB  of  Bednar  are  small  ulcers  on  the  hard  palate,  caused 
by  the  irritation  of  the  artificial  nipple  or  injury  inflicted  by  the  nurse's 
fingers.    They  are  not  of  serious  import. 

Parasitic  Stomatitis  (Thrush,  Mycotic  Stomatitis).— An  affection 
caused  by  the  growth  of  the  saccharomyces  albicans  upon  the  surface  of 
the  mucous  membrane  of  the  mouth. 

Etiology. — The  mycelial  filaments  form  a  dense  mesh  work  among  the 
epithelial  cells,  thus  producing  pearly  white  patches  that  coalesce  as  they 
grow  and  form  a  membrane  of  variable  extent.  The  fungus  does  not 
grow  upon  a  healthy  surface,  but  follows  a  catarrhal  stomatitis,  especially 
when  this  is  a  result  of  the  acid  fermentation  of  food.  Uncleanliness  of 
the  nursing-bottle  and  nipple  is  a  common  source  of  infection.  The  disease 
often  becomes  epidemic  in  foundling  asylums.  Although  more  prevalent 
in  infants,  it  is  sometimes  encountered  in  adults,  particularly  in  the  late 
stages  of  tuberculosis,  cancer,  diabetes,  and  other  cachectic  conditions. 

Symptoms. — The  fungus  generally  appears  first  on  the  tongue,  from 
which  it  extends  to  the  lips,  cheeks,  hard  palate,  and  often  to  the  tonsils 
and  pharynx.  It  has  been  found  also  in  the  esophagus,  stomach,  cecum, 
in  the  respiratory  passages,  and  in  a  few  instances  in  the  brain  and  blood- 
vessels. The  mouth  is  abnormally  dry.  The  distinctive  feature  of  the 
condition  is  the  fact  that  the  membranous  formation  can  be  scraped  off 
without  difficulty,  and  leaves  a  surface  that  is  intact  or,  at  most,  slightly 
eroded.    There  are  no  distinct  ulcers,  as  in  aphthous  stomatitis. 

Treatment. — The  disease  may  be  prevented  by  proper  attention  to  the 
cleansing  of  the  mouth  and  teeth.  The  constitutional  treatment  is  more 
important  than  the  local,  for  the  growth  often  proves  stubborn  in  the 
mouths  of  feeble  or  cachectic  patients.  The  disease  generally  yields 
promptly,  however,  to  proper  feeding,  with  proper  care  of  the  mouth,  the 
nipple  of  the  mother,  or  the  regular  disinfection  of  the  nursing-bottle  and 
its  nipple.  The  fungus  should  be  removed  as  fast  as  it  forms,  and  the 
surfaces  bathed  with  an  alkaline  solution.  Small  doses  of  calomel  are 
generally  specific  when  the  growth  extends  into  the  esophagus  and  stom- 
ach, and  are  doubtless  capable  of  preventing  such  extension. 

Ulcerative  Stomatitis  (Fetid  or  Putrid  Sore  Mouth).— This  affection 


432  PRACTICE  OF  MEDICINE 

is  a  destructive  ulceration  of  the  gums  met  with  in  children  after  the  first 
dentition;  occasionally,  also,  in  adults.  It  is  probably  contagious  and 
sometimes  becomes  epidemic  in  institutions  for  children  or  in  camps  and 
prisons. 

Etiology.  — Its  origin  is  probably  microbic,  but  the  specific  germ  is  not 
known.  It  is  favored  by  improper  food,  dampness,  faulty  sanitation, 
sudden  changes  of  temperature,  but  more  particularly  by  lack  of  cleanli- 
ness in  the  care  of  the  mouth  and  teeth.  Attempts  have  been  made  to 
identify  it  with  the  foot-and-mouth  disease  of  cattle  and  with  contagious 
impetigo,  but  the  relationship  has  not  been  demonstrated.  Chronic 
poisoning  with  mercury,  lead,  arsenic,  copper,  phosphorus,  and  iodin, 
and  the  presence  of  catarrhal  stomatitis,  favor  its  development.  It  often 
accompanies  or  follows  the  acute  infections,  and  is  comrpon  in  tubercu- 
lous, rachitic,  or  syphilitic  children.  An  accumulation  of  tartar  assists 
in  its  production. 

Symptoms. — The  disease  begins  at  the  margin  of  the  gum,  and  extends 
in  all  directions  often  passing  across  to  the  contiguous  surface  of  the  lip 
or  cheek.  The  gum  is  at  first  swollen,  intensely  red,  and  bleeds  readily. 
It  becomes  everted  and  detached  from  the  teeth.  Ulcers  soon  form  along 
the  edges,  covered  with  a  grayish  white,  firmly  adherent  membrane. 
Owing  to  the  destructive  process,  the  teeth  appear  elongated  and  in 
severe  cases  they  often  become  loosened.  The  periosteum  may  become 
involved,  and  a  greater  or  less  portion  of  the  alveolar  process  may  be 
detached;  actual  necrosis  is  unusual.  An  intense  catarrhal  stomatitis 
spreads  over  the  tongue,  lips,  and  cheeks,  but  ulcers  are  seldom  formed. 
The  saliva  is  enormously  increased  in  quantity;  the  breath  is  rendered 
fetid  by  the  necrotic  tissue,  and  mastication  is  extremely  painful.  Fever, 
anemia,  and  emaciation  develop  rapidly,  and  death  sometimes  occurs  in 
feeble  children.  In  older  children,  however,  there  may  be  no  constitu- 
tional reaction.    The  lymph-glands  below  the  jaw  are  usually  swollen. 

Treatment. — Potassium  chlorate  is  a  specific  in  all  cases.  It  should  be 
given  to  a  child  in  doses  of  gr.  ij  to  x  (0.13 — 0.65)  three  times  daily  in 
aqueous  solution  without  sirup.  The  same  solution  may  be  employed  as 
a  wash,  but  it  is  painful  in  the  early  stage  of  ulceration.  Potassium 
permanganate  solution  (i  1500)  diminishes  the  fetor.  The  application 
of  silver  nitrate  promotes  healing.  The  action  of  potassium  chlorate  on  a 
young  infant  should  be  watched,  and  the  remedy  should  be  discontinued 
immediately  upon  evidence  of  renal  irritation,  the  first  symptom  of  which 
is  usually  albuminuria  or  persistent  drowsiness. 

Gangrenous  Stomatitis  (Noma,  Cancrum  Oris).— A  rapidly  progress- 
ing gangrenous  process  beginning  on  the  inner  surface  of  one  cheek  or 
on  the  gum,  and  resulting  in  extensive  destruction  of  tissues. 

Etiology. — The  disease  is  probably  due  to  a  micro-organism,  and  sev- 
eral bacteria  have  been  described  as  the  specific  cause.  The  diphtheria 
bacillus,  or  one  identical  with  it,  has  been  found  by  several  investigators 
in  a  considerable  number  of  successive  cases.  The  disease  ordinarily 
occurs  between  the  ages  of  2  and  15  and  more  frequently  in  girls.  It 
usually  follows  an  acute  infection,  more  than  half  the  cases  having  oc- 
curred after  measles,  some  after  diphtheria,  and  several  after  ulcerative 
stomatitis,  but  it  may  arise  as  a  primary  affection  under  extremely  poor 
sanitary  conditions. 


STOMATITIS  433- 

Symptoms.— The  affection  generally  begins  as  a  small  papule  or  vesicle 
on  the  mucous  membrane  of  the  cheek,  and,  before  it  is  discovered,  it  has 
usually  developed  into  a  gangrenous  ulcer  which  spreads  with  rapidity. 
In  some  cases  it  is  preceded  by  a  catarrhal  stomatitis.  The  surrounding 
tissues  become  extremely  hyperemic.  The  necrotic  process  frequently 
extends  to  the  lips  and  gums,  rarely  involving  also  the  tongue,  and 
within  48  hours  the  cheek  is  often  perforated  by  it.  The  vessels  in  the 
hyperemic  zone  become  thrombotic,  and  the  adjacent  lymph-glands  be- 
come large  and  soft.  In  extreme  cases,  unless  death  occurs  early,  the 
entire  side  of  the  face  becomes  involved,  the  entire  cheek,  the  eye,  nose, 
soft  palate,  and  frontal  bone;  sometimes  the  ear  and  tissue  back  of  it  and 
the  maxillae  are  destroyed.  Metastasis  to  the  lungs  may  occur,  with  the 
production  of  fatal  bronchopneumonia,  infarction,  abscess,  or  gangrene. 
The  odor  is  extremely  fetid  and  characteristic.  Salivation  is  produced 
and  fragments  of  necrotic  tissue  are  discharged,  or  they  may  be  swal- 
lowed and  produce  nausea  and  diarrhea.  Albuminuria  is  commonly 
developed.  The  constitutional  disturbances  are  severe.  The  child  be- 
comes prostrated  at  once,  and  the  temperature  rapidly  rises  to  104°  F. 
(40°  C);  the  pulse  is  rapid  and  weak.  The  process  is  not  usually 
attended  with  much  pain.  The  mortality  is  fully  90  per  cent;  death 
occurs  in  7  to  1 4  days,  sometimes  much  earlier.  Recovery  is  sometimes 
spontaneous  or  follows  active  treatment. 

Treatment. — As  soon  as  the  primary  lesion  has  been  discovered,  it 
should  be  thoroughly  destroyed,  under  anesthesia,  with  the  electric  or 
Paquelin  cautery  or  fuming  nitric  acid.  The  mouth  should  then  be 
cleansed  at  least  every  two  hours  with  a  solution  of  hydrogen  peroxid 
followed  with  a  solution  of  potassium  permanganate  (i  :5oo).  The 
wound  should  be  dressed  with  iodoform  or  other  antiseptic  gauze.  Liquid 
nourishment  and  stimulants  (whisky  or  brandy)  must  be  adminis- 
tered freely  and  at  short  intervals,  by  the  rectum  if  necessary.  Strychnin 
may  be  administered  hypodermically. 

Membranous  Stomatitis  (Diphtheritic  or  Croupous  Stomatitis).— This 
form  of  stomatitis  is  characterized  by  the  formation  of  a  false  membrane. 
It  may  be  caused  by  the  Klebs-Loffler  bacillus,  or  by  the  corrosive 
action  of  strong  acids  or  alkalis,  heat  or  cold,  or  gonorrheal  or  syphil- 
itic infection.  It  is  differentiated  from  mycotic  stomatitis  by  the  firmness 
with  which  the  membrane  adheres  to  the  mucous  membrane,  especially 
when  of  true  diphtheritic  character.  The  treatment  is  that  of  diphtheria, 
except  that  the  antitoxin  is  not  used  when  the  bacillus  is  absent. 

Syphilitic  Stomatitis.    (See  Symptoms  of  Syphihs,  page  164.) 

Mercurial  Stomatitis  (Ptyalism).— An  inflammation  of  the  mouth, 
tongue,  and  salivary  glands,  caused  by  mercury.  A  similar  inflammation 
is  occasionally  produced  by  other  drugs,  as  iodin  and  jaborandi. 

Etiology. — The  disease  may  be  produced  by  any  form  of  mercury  in- 
troduced into  the  system  in  any  manner  whatever.  It  rarely  occurs  as 
a  result  of  the  treatment  of  syphihs,  and  it  is  now  seldom  seen  except  in 
persons  abnormally  susceptible  to  the  action  of  the  drug,  or  as  a  result 
of  the  continued  use  of  calomel  as  a  diuretic.  It  may,  however,  follow 
a  single  dose  of  but  a  few  grains. 

Symptoms.— The  first  manifestation  is  generally  a  metallic  taste;  then 
the  gums  become  red,  swollen,  and  painful  (gingivitis),  and  the  flow  of 
28 


434  PRACTICE  OF  MEDICINE 

saliva  is  greatly  increased.  The  tongue  is  sometimes  affected.  The 
breath  is  foul.  Ulcerative  stomatitis  is  sometimes  produced.  In  extreme 
cases  the  teeth  become  loose  or  completely  detached.  Mastication  is 
painful  or  impossible.  The  patient  becomes  pale,  emaciated,  and  some- 
times feverish.    Albuminuria  may  be  produced. 

Treatment. — The  administration  of  mercury  should  be  immediately 
suspended.  A  solution  of  potassium  chlorate  should  be  used  to  rinse  the 
mouth,  and  in  severe  cases  it  should  be  administered  internally;  or  the 
permanganate  may  be  used  as  a  rinse  and  the  chlorate  internally.  A 
saline  purge  should  be  given,  and  the  patient  should  drink  freely  of  water 
to  promote  diuresis.  Sweating  is  beneficial.  Atropin,gr.  1-100(0.0006), 
diminishes  the  flow  of  saliva. 

La  Perleche. — An  affection  consisting  of  the  formation  of  painful 
fissures  at  the  angles  of  the  mouth.  The  disease  occurred  epidemically 
among  children  in  France  in  1886  and  was  communicated  through  the 
drinking-cups.  The  name  was  suggested  by  the  constant  licking  of  the 
fissures.  The  treatment  consists  in  the  application  of  astringent  solu- 
tions, especially  alum  and  cupric  sulphate. 

Riga's  Disease. — A  grayish  membrane  forms  over  the  frenum  of  the 
tongue,  accompanied  with  much  induration.  Ulcers  may  form  beneath 
it.  It  usually  appears  with  the  irruption  of  the  first  teeth.  The  affec- 
tion occurred  as  an  epidemic  in  Italy.  The  treatment  is  that  of  catar- 
rhal stomatitis. 

Ludwig's  Angina  (Cellulitis  of  the  Neck). — An  acute,  suppurative 
inflammation  beginning  in  the  floor  of  the  mouth  and  extending  to  the 
cellular  tissues  of  the  front  of  the  neck.  It  is  due  to  streptococcus  in- 
fection, but  occurs  most  frequently  in  a  secondary  relation  to  the  infec- 
tions, particularly  scarlatina  or  diphtheria.  It  may  originate  in  the 
adjacent  glands,  after  trauma.  Mastication,  deglutition,  and  articulation 
become  painful.  Edema  of  the  glottis  may  develop.  Abscess  or  extensive 
sloughing  is  usual.  Symptoms  of  septic  infection  are  common.  The 
treatment  is  surgical,  consisting  of  the  evacuation  of  the  pus  and  re- 
moval of  sloughs. 

DISEASES  OF  THE  TONGUE. 

GLOSSITIS. 

1.  Acute  Glossitis. — An  acute  inflammation  of  the  tongue  caused  by 
burns,  corrosives,  injury  by  foreign  bodies  or  carious  teeth,  or  the  sting 
of  insects.  It  is  not  a  common  affection.  The  tongue  rapidly  becomes 
swollen,  red,  and  painful,  and  may  protrude  from  the  mouth.  The  soft 
palate  and  epiglottis  may  also  become  edematous,  and  the  sublingual 
glands  are  generally  enlarged.  Fever,  headache,  and  languor  are  usual 
symptoms.  Recovery  occurs,  as  a  rule,  after  a  week.  The  treatment  con- 
sists in  the  application  of  alkaline  solutions.  When  the  swelling  is  not 
too  great,  fragments  of  ice  should  be  held  in  the  mouth.  A  calomel 
purge  is  beneficial. 

2.  Chronic  Glossitis. — This  may  result  from  repeated  attacks  of  acute 
glossitis,  or  it  may  develop  gradually  as  a  result  of  the  irritation  of 


DISEASES  OF  THE  SALIVARY  GLANDS  435 

tobacco,  alcohol,  or  carious  teeth.  It  often  accompanies  impaired  diges- 
tion. The  tongue  becomes  large,  inflamed,  and  painful,  and  in  places 
denuded  of  its  papillae.  The  treatment  requires  the  removal  of  the  cause 
and  the  application  of  a  2  per  cent  silver-nitrate  solution.  Tonics  are 
generally  indicated. 

3.  Glossitis  Desiccans. — This  is  a  chronic  disease  of  unknown  origin, 
in  which  the  surface  of  the  tongue  becomes  denuded,  fissured,  and  ex- 
tremely sensitive.  Its  appearance  is  ragged  and  uneven.  The  treatment 
is  the  same  as  that  of  chronic  glossitis. 

4.  Geographical  Tongue  (Lingual  Psoriasis,  Eczema  of  the  Tongue).— 
The  tongue  becomes  denuded  of  its  surface  epithelium  in  patches  which 
spread  in  all  directions  while  the  central  portion  heals.  A  narrow  white 
line  sometimes  borders  the  patch  and  increases  its  resemblance  to  the 
outlines  of  a  map.  A  sense  of  burning  and  itching  is  usually  produced. 
The  aftection  sometimes  becomes  chronic  and  often  relapses  after  ap- 
parent cure.  Its  cause  is  not  known ;  it  occurs  at  any  time  of  life.  The 
treatment  is  that  of  chronic  stomatitis. 

5.  Leukoplakia  Buccalis  (Smoker's  Tongue,  Buccal  Psoriasis,  Ich- 
thyosis Linguae). — A  disease  of  unknown  origin  consisting  of  the  forma- 
tion of  irregular,  unsymmetrical,  smooth  white  patches  which  do  not 
ulcerate.  The  epithelial  layer  often  becomes  greatly  thickened  and  the 
papillae  may  be  hypertrophied,  producing  warty  pronjinences  (lingual 
corns).  It  is  often  met  with  in  excessive  smokers,  but  may  be  inde- 
pendent of  such  irritation.  It  is  probably  not  related  to  syphilis.  It  is 
painful  and  often  persistent.  The  patches  must  generally  be  removed 
with  the  curette,  cautery,  or  chromic  acid.  Ravitch  recommends  the 
applying  of  a  1 5  per  cent  solution  of  silver  nitrate  or  5  per  cent  chromic 
acid,  to  be  followed  by  the  negative  galvanic  current  for  10  or  15  min- 
utes each  day.  The  indication  for  radical  treatment  is  the  liability  of 
the  papillomatous  formation  to  become  epitheliomatous. 

6.  Macroglossia,  a  congenital  enlargement  of  the  tongue  due  either  to 
hypertrophy  of  muscle  or  the  presence  of  a  lymphangioma.  The  tongue 
may  become  deeply  fissured  and  painful.  A  similar  enlargement  is  some- 
times associated  with  acromegaly,  myxedema,  and  cretinism.  The  treat- 
ment of  the  congenital  disease  is  surgical  and  consists  in  the  removal  of 
wedge-shaped  pieces  of  the  tongue. 

7.  Hemiglossitis. — This  name  is  applied  to  a  vesicular  eruption  that 
is  sometimes  seen  on  the  side  of  the  tongue  and  inner  surface  of  the 
cheek,  apparently  bearing  a  relation  to  the  terminal  filaments  of  the 
trigeminal  nerve  and  thought  to  be  of  the  same  nature  as  herpes  zoster. 

8.  Epithelioma  of  the  Tongue. — This  presents  a  persistent,  gradually 
enlarging  ulceration,  with  indurated  edges,  along  the  sides  or  at  the 
base  of  the  tongue.  Good  results  are  obtained  from  treatment  with  the 
X-ray.    This  failing,  the  new  growth  must  be  excised. 

DISEASES  OF  THE  SALIVARY  GLANDS. 

I.  Supersecretion  (Ptyalism). — An  excessive  secretion  of  saliva,  some- 
times amounting  to  5  quarts  (liters)  in  24  hours;  the  specific  gravity 
may  rise  to  1.030  or  higher.  The  causes  are  many.  Nearly  all  the  in- 
flammatory conditions  of  the  mouth  are  attended  with  salivation;   it 


436  PRACTICE  OF  MEDICINE 

may  be  produced  by  reflex  irritation  of  the  nerves  governing  the  secre- 
tion. It  occurs  at  times  in  connection  with  mental  and  nervous  disease, 
hydrophobia,  or  the  acute  fevers.  It  has  been  observed  during  gestation 
and  in  connection  with  disease  of  the  pancreas.  It  is  more  frequently, 
however,  a  result  of  mercurial  poisoning;  it  may  be  induced  also  by 
iodin,  copper,  gold,  silver,  arsenic,  or  lead  and  by  the  vegetable  drugs, 
jaborandi  (pilocarpin),  muscarin,  and  tobacco.  The  condition  generally 
subsides  upon  removal  of  the  cause;  in  nervous  diseases  it  may  prove 
persistent.    The  local  treatment  is  that  of  mercurial  stomatitis. 

2.  Xerostomia  (Aptyalism,  Dry  Mouth).— An  arrest  of  the  salivary 
secretion.  This  disease  is  rare  and  is  generally  encountered  in  neurotic 
women.  The  tongue  becomes  dry  and  red,  sometimes  fissured;  the  mucous 
membrane  is  smooth  and  glazed;  mastication,  deglutition,  and  articula- 
tion become  difficult,  and  the  food  may  collect  along  the  gums  in  a  hard- 
ened mass.  A  similar  dryness  often  occurs  in  diabetes.  Pilocarpin  may 
stimulate  the  secretion,  but  the  galvanic  current  has  proved  more  suc- 
cessful. 

3.  Inflammation  of  the  Salivary  Glands. 
((2)   Specific  Parotitis.    (^See  Mumps,  page  144.) 

QT)  Symptomatic  Parotitis  (Secondary  Parotitis,  Parotid  Bubo). — An 
acute  swelling  of  the  parotid  gland,  usually  a  result  of  septic  infec- 
tion reaching  the  gland  through  the  duct  or  through  the  blood.  It  is 
seen  especially  in  connection  with  or  as  a  sequence  of  the  infectious 
diseases,  particularly  typhoid  fever,  typhus,  sometimes  in  pneumonia, 
tuberculosis,  pyemia,  or  syphiHs.  It  has  been  observed  also  in  connection 
with  abdominal,  pelvic,  or  genitourinary  disease  or  injury,  and  in  a  few 
cases  it  has  been  attributed  to  the  influence  of  menstruation,  pregnancy, 
or  the  introduction  of  a  pessary.  Gowers  saw  it  in  a  case  of  fatal 
peripheral  neuritis.  The  treatment  consists  in  eff'orts  to  prevent  suppura- 
tion through  the  application  of  ice,  leeches,  iodin,  mercurial  or  guaiacol 
ointment.  An  incision  should  be  made  immediately  upon  the  develop- 
ment of  pus,  and  a  poultice  may  then  be  applied. 

(<:)  Chronic  Parotitis.— A.  chronic  enlargement  of  the  parotid  gland 
has  been  observed  as  a  result  of  mumps,  mercurial  or  lead  intoxication, 
inflammation  of  the  throat,  and  in  the  course  of  chronic  nephritis. 

(^)  Gaseoics  distejition  of  the  gland  and  duct  occurs  in  glassblowers 
and  cornet-players;  suppuration  may  be  produced.  The  distention  can 
sometimes  be  relieved  by  catheterization  of  the  duct. 

DISEASES  OF  THE  PHARYNX. 

I.  Circulatory  Disturbances.— (rt;)  i7>/^r(?w?/fl!  is  commonly  associated 
with  acute  and  chronic  diseases  of  the  throat.  It  is  a  constant  condi- 
tion in  smokers.  Passive  congestion  is  seen  also  as  a  result  of  obstruc- 
tion of  the  circulation  in  the  vena  cava  by  aneurism,  neoplasm,  or  valvu- 
lar disease  of  the  heart.  It  generally  subsides  upon  removal  of  the 
cause.    A  2  per  cent  solution  of  silver  nitrate  may  be  applied. 

(Ji)  Anemia  is  observed  chiefly  in  connection  with  general  anemic 
conditions,  as  after  hemorrhage  and  in  chlorosis. 

(^)  Ulcers  sometimes  result  from  chronic  pharyngitis,  but  much  more 
frequently  from  tuberculosis,  syphihs,  the  general  debility  of  long-stand- 


DISEASES  OF  THE  PHARYNX  437 

ing  disease,  as  lupus,  cancer,  or  nephritis,  or  from  septic  infection  con- 
tracted in  hospital  or  the  dissecting-room.  The  treatment  consists  in 
the  improvement  of  the  general  condition  and  the  application  of  silver 
nitrate. 

(^)  Edema  of  the  pharynx  ajid  uvula  occurs  in  quinsy,  chronic  ne- 
phritis, profound  anemias,  and  other  debilitated  conditions.  The  enlarge- 
ment of  the  uvula  may  interfere  with  deglutition  and  respiration,  espe- 
cially when  there  is  congenital  elongation.  The  serum  may  be  evacuated 
by  puncture  or  by  snipping  off  the  tip  of  the  uvula  when  elongated. 
Hot  gargles  should  be  employed.  Treatment  of  the  general  condition  is 
even  more  important  in  many  cases  than  local  treatment. 

(^)  Hemorrhage  of  the  pharynx  is  sometimes  associated  with  that  of 
other  mucous  membranes.  The  blood  may  be  retained  and  form  a 
hematoma.  Vomiting  of  blood  (hematemesis)  may  occur  after  a  large 
quantity  has  been  swallowed.  The  condition  may  be  mistaken  also  for 
hemoptysis,  and  for  this  reason  the  pharynx  should  always  be  examined 
in  a  case  of  moderate  spitting  of  blood.  The  blood  may  come  from 
granulations  in  the  nasopharynx,  and  can  then  be  seen  trickling  down 
the  posterior  wall.  It  can  generally  be  arrested  by  the  application  of 
astringents  or  the  peroxid  of  hydrogen. 

2.  Neuroses  of  the  Pharnyx.— These  occur  especially  as  a  result  of 
neurotic  conditions,  bulbar  paralysis,  hydrophobia,  tetanus,  or  of  vari- 
cosity of  the  veins  of  the  throat,  reflex  irritation  of  an  enlarged  phar3ni- 
geal  tonsil,  or  growths  in  the  posterior  nares.  They  are  manifested  for 
the  most  part  as  hyperesthesia,  anesthesia,  paresthesia  (altered  or  un- 
natural sensation)  ;  less  frequently  as  spasms,  neuralgia  or  paralysis,  all 
of  which  conditions  interfere  with  deglutition  and  sometimes  impair  the 
sense  of  hearing.  The  treatment  is  usually  that  of  the  underlying  condi- 
tion. 

3.  Acute  Pharyngitis  (Sore  Throat,  Simple  or  Catarrhal  Angina).— 
An  acute  inflammation  of  the  pharynx,  generally  involving  also  the  uvula 
and  tonsils. 

Eiiology. — It  may  result  from  cold  or  the  inhalation  of  hot  or  irri- 
tating vapors,  but  it  is  frequently  a  part  of  a  general  nasopharyngeal 
catarrh.  It  is  doubtless  due  to  the  action  of  bacteria  in  some  cases, 
especially  when  it  is  associated  with  the  acute  infections.  Along  with 
inflammation  of  the  tonsils,  it  often  precedes  an  attack  of  rheumatism 
or  other  acute  disease.  It  may  be  induced  by  vomiting,  and  is  thus 
associated  with  gastric  catarrh. 

Symptoms. — It  may  set  in  with  a  slight  chill  and  fever,  and  a  burning 
soreness  of  the  throat.  This  is  sometimes  followed  with  stiffness  of  the 
neck,  glandular  enlargement,  tinnitus,  an  irritable  cough,  and  perhaps 
hoarseness,  from  extension  to  the  larynx.  Swallowing  and  speaking  be- 
come difficult.  The  pharynx  appears  red  and  swollen  and  is  usually 
coated  with  viscid  mucus. 

Treatment. — Gargling  with  hot  milk  or  tea,  sprays  containing  sodium 
bicarbonate  or  menthol,  and  lozenges  containing  alkalis  afford  great 
relief.  The  neck  may  be  rubbed  with  volatile  linament  or  camphorated 
oil,  and  covered  with  flannel.  A  purge  is  often  beneficial,  and  laxatives 
should  be  a  routine  treatment  with  most  patients  in  order  to  ward  off" 
recurrences. 


438  PRACTICE  OF  MEDICINE 

4.  Chronic  Pharyngitis  (Chronic  Ulcerative  or  Granular  Pharyngitis, 
Chronic  Angina,  Clergyman's  Sore  Throat).— A  chronic  inflammation  of 
the  mucous  membrane  of  the  pharynx,  involving  to  a  variable  extent  the 
other  structures  of  the  throat. 

Etiology. — The  disease  may  follow  repeated  attacks  of  the  acute  form. 
In  children  it  is  associated  with  chronic  hypertrophy  of  the  tonsils  and 
the  presence  of  adenoids.  It  is  induced  by  mouth-breathing,  and  it  may 
be  an  extension  of  a  catarrhal  process  from  the  nose.  It  is  a  common 
result  of  alcoholism  and  the  excessive  use  of  tobacco,  but  is  often  in- 
duced by  voice-strain  in  lecturers,  clergymen,  and  street-criers.  It  is 
probably  more  frequent  in  the  rheumatic  and  gouty  and  in  those  pre- 
disposed to  tuberculosis,  as  well  as  in  the  subjects  of  chronic  diseases  of 
the  heart  or  lungs. 

Symptoms. — There  is  usually  a  sense  of  dryness  or  of  irritation  of  the 
throat,  that  is  most  severe  in  the  morning,  and  accompanied  with  cough 
or  hawking,  huskiness  of  the  voice,  and  pain  upon  swallowing.  The 
secretion  is  often  abundant,  and  the  enlarged  follicles  can  be  distinctly 
seen  as  prominences  on  the  wall  of  the  pharynx,  but  later  the  follicles 
may  shrivel  and  the  pharynx  become  dry.  A  few  dilated  capillaries  usu- 
ally traverse  the  posterior  wall.  The  mucous  membrane  appears  relaxed 
and  the  uvula  may  be  elongated  and  swollen.  Chronic  disease  of  the 
sphenoid  occasionally  produces  a  purulent  discharge  that  flows  down  the 
wall  of  the  pharynx. 

Treatment. — Removal  of  the  cause  is  important,  and  the  general  con- 
dition of  the  patient  must  be  improved.  The  enlarged  follicles  should  be 
touched  separately  with  silver  nitrate  or  the  electric  cautery.  The  use  of 
astringent  gargles,  sprays,  and  pastilles  is  beneficial,  but  in  most  cases 
the  condition  proves  extremely  resistant  to  all  treatment.  Chronic 
atrophic  pharyngitis  results,  the  mucous  membrane  becoming  shrunken 
and  pale,  and  the  patient  is  greatly  annoyed  by  the  formation  of  crusts. 
Partial  deafness  often  results  from  involvement  of  the  orifices  of  the 
Eustachian  tube. 

5.  Retropharyngeal  Abscess.— This  affection  may  occur  in  healthy 
infants  or  young  children  as  a  result  of  septic  infection  which  cannot 
always  be  accounted  for,  or  it  may  follow  the  acute  infections.  As  a  re- 
sult of  caries  of  the  bodies  of  the  vertebras  it  may  assume  a  chronic  or 
recurrent  form.  The  swelling  may  be  so  great  as  to  interfere  with  swal- 
lowing and  even  to  threaten  asphyxia.  The  sound  of  the  voice  is  altered. 
The  neck  may  become  greatly  swollen.  The  wall  of  the  pharynx  is  in- 
tensely red,  and  the  abscess  can  generally  be  felt  with  the  finger. 

The  prognosis  is  grave,  on  account  of  the  danger  of  suffocation, 
pneumonia  from  the  aspiration  of  pus  when  rupture  occurs  during  sleep, 
septicemia,  edema  of  the  glottis,  or  perforation  of  a  blood-vessel,  the 
trachea,  or  esophagus. 

Treatment. — An  early  incision  should  be  made  when  the  abscess  can  be 
reached  through  the  mouth.  In  some  cases  the  pus  burrows  and  must 
be  evacuated  through  the  neck. 

6.  Acute  Infectious  Phlegmon. — This  name  has  been  given  to  a  rare, 
malignant  inflammation  which  begins  in  the  side  of  the  pharynx  and 
rapidly  passes  to  suppuration.  The  pus  burrows  down  the  neck  and 
may  reach  the  mediastinum.    The  side  of  the  neck  becomes  intensely 


DISEASES  OF  THE  TONSILS  439 

swollen,  red,  and  tender,  deglutition  painful,  and  respiration  may  be  ob- 
structed. Severe  constitutional  symptoms  of  a  septic  character  usually 
develop,  and  death  may  be  a  matter  of  but  a  few  days.  The  treatment 
is  purely  surgical  and  consists  in  the  evacuation  of  the  pus  when  it  can 
be  reached. 

DISEASES   OF  THE  TONSILS. 

ACUTE  TONSILITIS. 
Catarrhal,  Follicular,  Lacunar,  or  Ulcerative  Tonsilitis,  or  Amygdalitis. 

Definiiion. — An  acute  inflammation  of  the  mucous  membrane  of  the 
tonsils,  accompanied  with  soreness  of  the  throat  and  more  or  less  sys- 
temic disturbance. 

Etiology. — The  disease  is  ordinarily  a  part  of  a  general  pharyngitis. 
It  is  more  frequent  in  the  spring  and  affects  particularly  children  and 
young  adults.  It  often  appears  to  be  infectious,  attacking  simultane- 
ously several  members  of  the  same  family,  and  it  often  recurs  in  the 
same  individual  at  the  same  time  each  year.  Cold  and  poor  hygiene  are 
doubtless  influential  in  its  production.  Some  writers  regard  it  as  related 
to  rheumatism,  for  an  attack  of  tonsilitis  not  infrequently  precedes  the 
onset  of  rheumatism.  It  is  a  common  symptom  of  the  acute  exanthe- 
mata and  may  be  associated  with  or  follow  an  attack  of  indigestion. 

Morbid  Anatomy. — Several  forms  of  the  disease  are  recognized,  the 
most  important  of  which  are  :  (a)  The  superficial,  in  which  only  the 
mucous  membrane  of  the  surface  of  the  tonsils  is  involved,  and  (/^)  the 
lacunar  or  follicular,  in  which  the  mucous  membrane  of  the  crypts  is 
also  affected.  The  tonsils  are  enlarged  and  intensely  hyperemic,  and  the 
follicles  not  infrequently  become  filled  with  a  fetid,  cheesy  material  com- 
posed of  epithelium  and  micrococci.  The  exudation  from  several  follicles 
sometimes  blends  into  a  uniform  coating  resembling  the  false  membrane 
of  diphtheria.  Small  vesicles  like  those  of  herpes  have  been  observed  on 
the  tonsil  in  a  few  instances  (herpetic  tonsilitis) ;  (^)  a  suppurative 
form,  in  which  the  tissues  are  more  deeply  involved  and  the  inflammatory 
process  rapidly  goes  on  to  suppuration. 

Symptoms. — The  affection  may  begin  with  or  without  constitutional 
manifestations.  There  is  often  a  slight  chill  and  fever,  with  pain  in  the 
back  and  limbs.  The  temperature  often  reaches  104°  or  105°  F.  (40.0° — 
40.5°  C.)  in  children.  The  throat  is  sore,  and  swallowing  is  painful. 
Fluids  may  be  regurgitated  into  the  nose  on  account  of  the  swelling  of 
the  uvula.  The  tongue  is  furred,  the  tonsils  much  enlarged,  and  the 
crypts  filled  with  a  white  or  yellowish  exudate.  The  voice  is  nasal,  and 
articulation  may  be  difficult  and  painful.  The  inflammation  may  extend 
to  the  middle  ear  and  impair  the  hearing.  The  disease  does  not  usually 
last  longer  than  a  week.  Albuminuria  is  sometimes  present,  and  endo- 
carditis and  pericarditis  have  been  observed;  but  the  discovery  of  a 
systolic  apex  murmur  does  not  necessarily  indicate  an  endocarditis  in  a 
feverish  child.  Paralysis  does  not  follow  an  acute  tonsilitis  unless  it  is 
of  diphtheritic  character. 

Diagnosis.  —The  disease  is  to  be  differentiated  particularly  from  diph- 
theria.   In  the  latter  disease  the  membranous  formation  has  a  gravish 


440  PRACTICE  OF  MEDICINE 

color,  it  is  more  uniformly  spread  over  the  surface  of  the  tonsil,  and  is 
more  firmly  adherent,  leaving  a  bleeding  surface  when  forcibly  removed, 
and  it  is  not  usually  confined  to  the  tonsils.  Fever  is  not  generally 
present  at  the  beginning  of  the  disease.  The  presence  of  the  diphtheria 
bacillus  establishes  the  diagnosis. 

Treatment — As  a  prophylactic  measure  the  child  should  be  isolated 
and  confined  to  bed,  at  least  until  the  presence  of  diphtheria  has  been 
excluded.  The  fever,  headache,  and  joint  or  muscular  pains  are  relieved 
by  phenacetin  or  sodium  salicylate.  Aconite  is  highly  recommended  in  the 
lacunar  form.  The  diet  should  be  liquid  until  the  difficulty  in  swallowing 
subsides.  Cold  milk,  egg-nog,  and  ice-cream  are  the  most  acceptable 
food.  Hot  gargles  of  sodium  bicarbonate  or  borax  with  thymol,  or 
astringents  in  glycerin  and  water,  hot  tea  or  milk,  generally  afford  tem- 
porary relief.  A  folded  flannel  dipped  in  ice  water  should  be  applied  to 
the  neck  at  night  and  covered  with  oil-silk.  In  the  suppurative  form, 
hot  applications  are  better.  An  incision  should  be  made  as  soon  as 
fluctuation  can  be  detected.  This  is  usually  done  with  a  curved  bistoury 
guarded  nearly  to  the  point  with  a  strip  of  adhesive  plaster,  the  incision 
being  made  downward  and  parallel  to  the  anterior  pillars,  avoiding  the 
carotid  region.  Very  rarely  the  tonsil  reaches  an  extent  that  renders 
suffocation  imminent  before  suppuration  has  occurred.  The  necessity  of 
tracheotomy  as  the  only  means  of  saving  life  in  such  cases  should  be 
borne  in  mind. 

CHRONIC  TONSILITIS. 

Chronic  Nasopharyngeal  Obstruction,  Mouth-Breathing,  Aprosexia. 

Definiiion. — A  chronic  hypertrophy  of  the  tonsils  and  of  the  pharyn- 
geal adenoid  tissue. 

Etiology. — The  condition  generally  begins  about  the  third  or  fourth 
year,  but  may  be  congenital.  It  is  a  little  more  frequent  in  boys.  An 
inherited  predisposition  is  often  apparent,  and  it  is  favored  by  bad  hy- 
giene and  poor  food.  It  often  follows  diphtheria,  scarlet  fever,  or  measles. 
Repeated  attacks  of  acute  tonsilitis  produce  permanent  enlargement  in 
some  cases. 

Morbid  Anatomy. — The  enlargement  of  the  tonsils  is  due  to  an  in- 
crease of  all  their  constituents.  In  many  cases  the  hypertrophy  of  the 
lymphoid  tissue  predominates,  while  in  others,  especially  cases  of  long 
standing,  the  stroma  is  greatly  increased  and  the  glands  become  quite 
firm.    The  tonsils  are  usually  about  equally  affected. 

The  enlargement  of  the  adenoid  tissue,  the  so-called  pharyngeal  tonsil, 
is  sometimes  of  a  papillomatous  character  in  the  more  chronic  cases. 

Symptoms. — The  most  prominent  symptom  is  obstruction  of  respira- 
tion, due,  in  great  measure,  to  the  presence  of  the  adenoids.  The  disease 
develops  gradually.  The  child  becomes  restless  at  night  and  sleeps  with 
the  head  thrown  back  and  the  mouth  open.  The  obstruction  causes  loud 
snoring,  and  in  severe  cases  the  child  often  awakes  in  a  fright  as  though 
at  the  point  of  suffocation.  Next  the  child  acquires  the  habit  of  keeping 
the  mouth  open  during  the  day,  and  the  face  becomes  dull  and  expres- 
sionless, the  voice  nasal  and  indistinct,  especially  in  the  pronunciation 
of  the  sounds  /,  r,  m,  and  n.    The  hearing  often  becomes  defective.    The 


DISEASES  OF  THE  ESOPHAGUS  441 

secretion  of  mucus  is  increased  and  the  breath  becomes  foul.  Small 
cheesy,  foul-smelling  masses  from  the  crypts  are  often  brought  up  by 
coughing  or  hawking.    Taste  and  smell  are  also  affected  in  many  cases. 

One  of  the  most  important  results  of  the  obstruction  of  the  breathing 
is  the  production  of  deformities  of  the  chest,  especially  the  pigeon-breast, 
barrel-chest,  and  funnel-chest.  While  it  is  proljable  that  the  deformity  is 
more  readily  produced  in  a  rachitic  child,  it  may  be  independent  of  the 
latter  disease.  The  greatest  prominence  of  the  sternum  is  usually  in  the 
upper  part.  The  barrel-chest  is  associated  especially  with  asthma  and 
emphysema.  Among  the  more  remote  results  are  habit  chorea  of  the 
face,  dreams,  enuresis,  forgetfulness,  and  inaptitudeTor  study.  Headache 
is  a  common  complaint,  and  the  children  are  especially  susceptible  to  cold 
and  other  forms  of  infection. 

Diagnosis. — There  is  no  difficulty  in  recognizing  the  condition  in  a 
well-marked  case;  examination  of  the  throat  reveals  the  enlargement  of 
the  tonsils.  The  adenoid  vegetations  may  be  seen  through  the  throat 
mirror  or  they  can  be  felt  with  the  linger. 

Treatment. — An  attempt  may  be  made  to  reduce  the  enlargement  by 
the  local  application  of  astringents,  as  glycerite  of  tannin,  or,  better,  the 
compound  solution  of  iodin  in  glycerin,  applied  with  a  stiff  brush,  but  in 
most  cases  it  is  better  to  remove  the  tonsils. 

The  treatment  of  the  adenoids  is  of  greater  importance  than  that  of 
the  tonsils.  Their  removal  can  be  readily  accomplished  under  anesthesia, 
with  the  finger-nail,  or,  more  esthetically,  with  a  curette.  The  hemor- 
rhage is  usually  slight,  but,  if  persistent,  yields  to  astringents  or  a  spray 
of  adrenalin  solution  (i  :iooo).  It  is  sometimes  necessary  after  the 
operation  to  apply  a  bandage  or  chin-strap  at  night,  in  order  to  over- 
come the  habit  of  mouth-breathing.  The  child  should  have  the  benefit 
of  fresh  air,  sunshine,  and  good  food. 

Enlargement  of  the  Lingual  Tonsils.— Enlargement  of  the  so-called 
lingual  tonsils,  a  group  of  closed  follicles  at  the  root  of  the  tongue,  pro- 
duces the  sensation  of  a  foreign  body  lodged  in  the  throat,  causing 
repeated  swallowing  and  hawking.  It  is  usually  associated  with  pharyn- 
gitis,  and  the  treatment  is  the  same. 

DISEASES  OF  THE  ESOPHAGUS. 

ACUTE   ESOPHAGITIS. 

Etiology. — The  inflammation  may  be  (^a)  an  extension  of  disease  in 
the  pharynx  or  in  the  stomach;  (^b^  it  may  be  produced  by  mechanical 
or  chemical  irritation,  (<:)  the  passage  or  lodgment  of  foreign  bodies, 
or  (1^)  the  swallowing  of  corrosives.  It  frequently  follows  the  infections, 
typhoid  fever,  diphtheria,  smallpox,  or  pneumonia.  In  some  instances 
the  cause  cannot  be  discovered. 

IVlorbid  Anatomy. — The  inflammatory  process  may  be  confined  to  the 
mucous  membrance  or  it  may  extend  deeply  into  the  underlying  tissues. 
It  may  be  simple  or  catarrhal,  membranous  or  diphtheritic,  suppura- 
tive or  phlegmonous,  or  gangrenous.  The  epithelial  coat  is  lost,  the 
follicles  enlarged;  erosions  are  often  present,  and  ulcers  of  considerable 
depth,  rarely  perforating  the  entire  wall,  are  sometimes  formed  as  a 


442  PRACTICE  OF  MEDICINE 

result  of  corrosive  poisons.  The  membranous  form  may  be  due  to  diph- 
theria or  the  thrush  fungus,  and  an  interesting  form  is  described  in  which 
casts  of  a  greater  or  less  portion  of  the  tube  are  ejected  similar  to 
those  of  the  bronchi  in  fibrinous  bronchitis. 

Symptoms. — The  chief  symptom  is  pain  upon  swallowing,  a  burning 
sensation  which  may  last  for  hours  after  the  taking  of  food.  A  spasm 
is  sometimes  produced,  with  regurgitation  of  food.  As  the  disease  ad- 
vances, pus  and  blood  may  be  regurgitated.  Thirst  becomes  urgent,  and 
emaciation  results  from  the  inability  to  take  nourishment.  A  more  or 
less  constant  pain  beneath  the  sternum  is  usually  complained  of.  On  the 
other  hand,  there  may  be  extensive  disease  of  the  esophagus,  with  ulcera- 
tion, unattended  with  any  symptoms  of  prominence. 

Treatment. — The  diet  must  be  entirely  fluid,  or  rectal  feeding  may  be 
employed.  Bismuth  subcarbonate,  gr.  xv  (i.o),  with  sodium  bicarbonate, 
gr.  V  (0.3),  may  be  given,  suspended  in  mucilage  or  placed  dry  upon  the 
tongue.  Small  fragments  of  ice  and,  as  the  inflammation  subsides,  de- 
mulcent drinks  may  be  given. 

CHRONIC  ESOPHAGITIS. 

This  form  may  result  from  the  acute  or  it  may  be  produced  by  chronic 
alcoholism,  irritating  food,  the  lodgment  of  a  foreign  body,  stricture, 
varix,  cancer,  or  other  tumor.  The  mucous  membrane  becomes  greatly 
thickened,  ulcers  develop,  and  polyps  may  form.  There  may  be  pain  on 
swallowing,  and  regurgitation  of  food,  sometimes  coated  with  mucus. 
The  treatment  consists  in  the  removal  of  the  cause  and  the  administra- 
tion of  the  remedies  for  acute  esophagitis. 

Ulcer  is  usually  encountered  in  connection  with  acute  esophagitis, 
cancer,  or  other  neoplasms.  It  has  been  seen  also  after  typhoid  fever 
and  in  peptic  ulcer  of  the  cardiac  orifice  of  the  stomach.  The  condition 
is  rarely  recognized  during  life.  The  treatment  is  the  same  as  that  of 
peptic  ulcer. 

STRICTURE  OF  THE  ESOPHAGUS. 

Etiology. — Stricture,  or  stenosis,  is  produced  by  organic  changes  in 
the  wall  of  the  tube,  by  abnormal  internal  conditions,  or  through  pres- 
sure from  without.  Congenital  narrowing  has  been  observed.  Cicatricial 
contraction  results  from  corrosive,  tubercular,  syphilitic,  diphtheritic,  or 
smallpox  ulceration,  and  peptic  ulcer  at  the  cardia.  The  lumen  of  the 
tube  may  be  closed  by  a  polyp,  cancer,  or  other  neoplastic  growth.  The 
chief  sources  of  external  pressure  are  tumors  in  the  neck  or  mediastinum, 
enlarged  lymph-glands,  aneurism,  and  pericardial  eftusion. 

Morbid  Anatomy. — The  stenosis  may  occur  in  any  part  of  the  tube, 
generally  near  the  upper  or  lower  extremity,  and  rarely  involves  its  en- 
tire length.  It  is  usually  single.  A  diverticulum  may  be  formed,  or  the 
muscular  coat  above  the  constriction  becomes  greatly  hypertrophied 
and  the  tube  dilated. 

Symptoms. — A  gradually  increasing  difficulty  in  swallowing  is  usually 
observed.  The  food  seems  to  lodge  on  its  way  to  the  stomach,  and  for 
a  time  it  must  be  assisted  with  a  swallow  of  water.    As  the  stenosis 


DISEASES  OF  THE  ESOPHAGUS  443 

becomes  more  complete,  the  food  can  no  longer  be  forced  down,  and 
regurgitation  occurs— immediately  when  the  stricture  is  in  the  upper 
part,  sometimes  not  for  several  hours  when  it  is  near  the  cardiac  ex- 
tremity. The  ejected  matter  has  an  alkaline  reaction,  unless  changed  by 
the  formation  of  fatty  acids.  It  shows  no  indication  of  gastric  digestion. 
Auscultation  may  be  of  service  in  locating  the  stricture,  or  the  esophageal 
bougie  or  stomach-tube  may  be  employed  for  this  purpose.  The  use  of 
the  esophagoscope  is  a  more  recent  method.  The  X-ray  has  been  suc- 
cessfully employed  also,  after  giving  the  patient  a  large  dose  of  bismuth 
subnitrate  in  order  to  produce  a  shadow.  The  utmost  care  must  be  exer- 
cised in  passing  a  bougie  or  tube  in  a  case  of  long  standing,  for  the  wall 
of  an  aneurism  or  a  cancerous  mass  may  be  punctured,  even  when  the 
instrument  is  most  skillfully  used. 

Treatment.— The  patient  must  be  nourished  by  rectal  alimentation. 
Attempts  may  be  made  to  dilate  the  stricture  with  graduated  sounds, 
and  in  the  cicatricial  form  this  may  sometimes  prove  successful.  Elec- 
trolysis has  been  used  with  benefit.  Esophagotomy  or  gastrostomy 
may  be  resorted  to  in  extreme  cases.  No  attempt  should  be  made,  as  a 
rule,  to  dilate  the  carcinomatous  stricture. 

CANCER  OF  THE  ESOPHAGUS. 

Et/'o/ogy.— The  disease  is  generally  primary,  and  it  affects  most  fre- 
quently men  between  40  and  60  years  of  age.  It  is  more  common  in 
alcoholic  subjects,  and  may  follow  injury  by  a  foreign  body  or  chronic 
gastritis  from  any  cause.  The  type  of  cancer  is  generally  the  epithe- 
lioma. 

/morbid  Anatomy.— Some  writers  place  the  point  of  greatest  frequency 
in  the  upper  third,  others  at  the  lower  extremity,  of  the  tube ;  the  growth 
is  sometimes  found  at  the  point  of  crossing  the  left  bronchus.  An  annular 
mass  from  one  to  two  inches  in  length  is  often  formed.  It  may  involve 
only  the  mucous  membrane  or  the  entire  thickness  of  the  wall.  Ulcera- 
tion and  perforation  often  result,  with  evacuation  of  the  contents  into 
the  trachea,  bronchus,  mediastinum,  or  pericardium.  Secondary  growths 
develop  in  the  neighboring  lymph-glands. 

5//w/7fo/77S.— Gradually  increasing  dysphagia  is  complained  of,  and  a 
complete  stenosis  finally  develops.  The  food,  when  regurgitated,  is  often 
coated  with  bloody  mucus  after  ulceration  has  occurred,  or  pure  blood 
may  be  brought  up.  Fragments  of  the  cancer  are  sometimes  found.  Pe- 
riodical attacks  of  sharp  pain  are  not  uncommon.  Laryngeal  or  bron- 
chial cough  is  produced  by  pressure.  In  other  cases  there  are  no  symp- 
toms except  gradual  emaciation  and  the  development  of  a  .cachexia. 

Diagnosis.— The  history  of  the  case  usually  excludes  spasm,  stricture, 
and  foreign  bodies,  for  sudden  occlusion  does  not  occur.  The  emacia- 
tion, pain,  and  cachexia,  in  a  man  past  middle  life,  with  regurgitation  of 
blood,  should  arouse  suspicion  of  the  disease.  The  tumor  may  be  lo- 
cated by  the  careful  passage  of  the  stomach-tube. 

Prognosis.— The  disease  is  invariably  fatal.  Death  occurs  from  as- 
thenia or  from  perforation  of  the  cancerous  ulcer. 

Treatment.— This  is  purely  palliative  in  most  cases.  The  patient  can 
generally  be  nourished  with    liquids,    milk,    predigested    beef,    egg-nog. 


444  PRACTICE  OF  MEDICINE 

broths,  and  gruels  until  a  late  stage  has  been  reached,  when  rectal  feed- 
ing must  be  resorted  to.  Pain  requires  the  administration  of  morphin. 
The  patient's  life  may  often  be  prolonged  by  an  early  gastrostomy. 

NEUROSES  OF  THE  ESOPHAGUS. 

Spasm  of  the  Esophagus.— This  affection  is  generally  met  with  in 
neurotic  individuals,  in  connection  with  hysteria,  hypochondriasis,  epi- 
lepsy, or  chorea,  and  sometimes  in  hydrophobia.  It  has  been  observed 
during  pregnancy  and  in  connection  with  ovarian  or  uterine  disease.  It 
may  follow  a  choking  fit  or  such  emotional  excitement  as  anger  or 
fright.  It  is  sometimes  a  result  of  gastric  irritation  or  a  reflex  influence 
from  the  respiratory  passages,  and  it  sometimes  occurs  in  persons  debili- 
tated by  neurasthenia,  tuberculosis,  or  other  chronic  disease. 

Symptoms.— The  spasm  generally  develops  suddenly.  It  may  affect 
any  part,  but  more  usually  the  upper  or  lower  extremity  of  the  tube. 
The  food  is  regurgitated,  and  for  a  time  all  efforts  to  overcome  the  ob- 
struction are  futile.  Hiccough,  pain,  palpitation,  and  a  sense  of  contric- 
tion  generally  accompany  the  attack.  The  spasm  is  sometimes  caused 
only  by  certain  articles  of  food,  and  fluids  can  generally  be  swallowed. 
The  attacks  recur  at  variable  intervals,  sometimes  daily,  sometimes  not 
for  weeks ;  and  the  duration  of  each  attack  is  equally  indefinite,  some- 
times lasting  for  only  a  few  moments,  sometimes  for  days  at  a  time, 
until  dilatation  is  finally  produced.  The  bougie  may  pass  without  diffi- 
culty. The  diagnosis  is  established  by  anesthetizing  the  patient,  when 
the  spasm  will  be  found  to  have  completely  subsided.  The  affection  is 
not  usually  serious,  but  fatal  cases  have  been  recorded. 

Treatment.— The  treatment  is  that  of  the  causative  condition.  The 
passage  of  the  bougie  often  cures  a  hysterical  case.  The  valerianates, 
asafetida,  and  the  bromids  are  usually  administered.  The  patient  should 
be  persuaded  to  swallow  food  in  the  presence  of  the  physician,  in  order  to 
overcome  his  fear  of  spasm. 

Globus  Hystericus.— This  name  is  given  to  the  sensation  of  a  lump 
rising  in  the  throat  and  threatening  suftbcation.  It  is  a  hysterical 
manifestation  and  is  generally  accompanied  with  repeated  efforts  at  swal- 
lowing, and  dyspnea.  It  is  promptly  reheved  by  remedies  which  quiet  the 
hysterical  seizure,  as  the  bromids  and  the  valerianates. 

Hyperesthesia  occurs  in  the  same  class  of  nervous,  hypochondriacal,  or 
neurasthenic  patients.  It  is  indicated  by  a  sense  of  burning  or  soreness 
in  swallowing,  without  evidence  of  inflammation.  It  may  precede  or  ac- 
company spasm. 

Anesthesia  occurs  either  as  a  hysterical  manifestation  or  in  connection 
with  paralysis.  It  is  indicated,  not  so  much  by  an  absence  of  sensation, 
as  by  the  slow  passage  of  food. 

Paralysis  is  a  rare  condition.  It  may  be  the  result  of  central  disease, 
as  bulbar  paralysis,  or  of  peripheral  neuritis  from  diphtheria  toxemia  or 
metallic  poisoning.  It  may  occur  in  a  hysterical  person.  It  has  been 
attributed  also  to  myositis  and  adhesions.  The  food  is  regurgitated, 
sometimes  after  long  intervals.  Swallowing  provokes  coughing,  and  there 
is  always  danger  of  the  aspiration  of  particles  of  food  into  the  lungs. 
The  patient  rapidly  becomes  emaciated.     The  treatment  consists  in  sup- 


DISEASES  OF  THE  STOMACH  445 

plying  nourishment  through  the  stomach-tube,  and  the  appHcation  of  a 
weak  faradic  current,  while  the  constitution  is  built  up  with  bitter  tonics, 
especially  strychnin. 

Dilatation. — This  is  almost  never  primary,  but  is  usually  a  result  of 
stricture,  and  affects  the  part  of  the  esophagus  immediately  above  the 
constriction.  Hypertrophy  of  the  wall  accompanies  the  dilatation.  The 
food  is  regurgitated,  sometimes  after  a  considerable  quantity  has  been 
swallowed,  and  respiration  may  be  interfered  with. 

Diverticula. — Saccular  dilatations  are  of  two  kinds,  those  due  to  pres- 
sure (pulsion)  and  those  due  to  traction.  The  former  are  usually 
found  on  the  posterior  wall  at  the  junction  of  the  pharynx  and  esopha- 
gus. A  small  dilatation  is  gradually  increased  by  the  pressure  of  food 
within  it  until  a  distinct  pouch  has  been  formed.  Traction  diverticula 
are  generally  situated  on  the  anterior  wall  near  the  bifurcation  of  the 
trachea.  They  are  generally  produced  by  the  contraction  of  cicatricial 
bands  resulting  from  a  previous  inflammation  of  the  lymph-glands. 

Foreign  Bodies. — Such  foreign  bodies  as  fishbones,  pins,  buttons, 
coins,  pieces  of  bone,  false  teeth,  and  numerous  other  articles  sometimes 
lodge  in  the  esophagus.  When  of  a  harmless  character  the  foreign  body 
may  be  carried  on  into  the  stomach  with  such  food  as  bread  or  potatoes 
swallowed  in  large  mouthfuls.  Or  the  patient  may  drink  a  glassful  of 
milk,  and  20  minutes  later  take  an  emetic.  The  foreign  body  may  be 
dislodged  by  the  coagulated  milk.  Another  method  is  to  have  the  pa- 
tient swallow  a  mass  of  tangled  thread.  An  hour  or  two  later  the  for- 
eign body  can  sometimes  be  withdrawn  with  the  thread. 

Rupture  of  the  esophagus,  when  not  a  result  of  cancer  or  ulcer,  is 
generally  produced  by  violent  vomiting.  It  is  most  frequently  encoun- 
tered in  intoxicated  persons.    It  is  always  fatal. 

Varix. — The  veins  at  the  lower  end  of  the  esophagus  sometimes  become 
dilated  as  a  result  of  hepatic  cirrhosis  or  valvular  disease  of  the  heart; 
chronic  esophagitis  is  induced,  and  a  fatal  hemorrhage  often  follows 
rupture  of  the  vessels. 

Hemorrhage  occurs  also  in  connection  with  ulcers  and  cancer  or  from 
the  injury  inflicted  in  the  passage  of  a  foreign  body.  Profuse  hemor- 
rhage follows  the  rupture  of  an  aneurism  into  the  esophagus.  It  some- 
times occurs  also  in  purpura  and  pernicious  anemia. 


DISEASES   OF   THE   STOMACH. 

The  stomach  is  so  situated  that  its  cardiac  orifice  normally  lies  behind  the  seventh 
left  costal  cartilage,  one  inch  from  the  sternum  and  four  inches  from  the  surface.  The 
pyloric  orifice  is  less  than  three  inches  to  the  right  of  the  cardiac  when  the  viscus  is 
empty,  but  it  lies  behind  the  left  lobe  of  the  liver  when  distended.  The  fundus  rises  to 
the  level  of  the  fifth  rib.  The  line  of  the  greater  curvature  varies,  but  it  seldom  sinks 
below  midway  between  the  xiphoid  cartilage  and  the  umbilicus  in  a  healthy  person.  The 
blood  supply  of  the  stomach  is  received  from  the  three  branches  of  the  celiac  axis,  and 
the  residual  blood  is  returned  to  the  splenic  and  superior  mesenteric  veins.  The  nerve 
supply  consists  of  the  terminal  branches  of  the  two  pneumogastrics,  convej'ing  impulses 
from  the  central  system,  and  of  branches  from  the  solar  plexus  of  the  sympathetic  sj^s- 
tem.  The  normal  capacity  of  the  stomach  is  from  1.500  to  1,700  c.  c.  (3 — 3',,  pints). 
The  gastric  secretion  consists  of  the  true  secretion  of  the  peptic  glands  and  mucus  from 
the  columnar  cells  found  on  the  surface  and  in  the  mouths  of  the  glands.  The  secretion 
proper  contains,   in  addition  to  inorganic  salts,  hydrochloric  acid  and  two  enzymes,  pep- 


446  PRACTICE  OF  MEDICINE 

sin,  which  acts  upon  proteids,  and  rennin,  which  has  the  power  of  coagulating  the  casein 
of  milk.  It  is  normally  almost  colorless,  of  acid  reaction  and  characteristic  odor.  Its. 
specific  gravity  is  usually  between  1.002  and  1.003.  The  acidity  is  chieil3^  if  not  wholly, 
due  to  hydrochloric  acid,  and  amounts  to  0.2,  rarely  0.3  per  cent. 

EXAMINATION  OF  THE  STOMACH. 

The  examination  of  the  stomach  includes  the  apphcation  of  the  usual 
methods  of  physical  diagnosis — inspection,  palpation,  percussion,  and 
auscultation— and  the  chemical,  microscopic,  and  bacteriologic  examina- 
tion of  its  contents.  Many  mechanical  devices  have  recently  been  intro- 
duced which  render  it  possible  to  illuminate  the  interior  of  the  stomach, 
determine  its  size,  and  outline  its  form  with  considerable  accuracy. 

Inspection. — It  is  only  when  the  stomach  is  distended  that  its  outline 
becomes  distinguishable  by  inspection.  Peristaltic  movements  can  some- 
times be  recognized,  and  they  may  be  induced  in  some  individuals  by 
applying  heat  or  cold  to  the  abdominal  wall  or  by  tapping  with  the 
finger.  The  stomach  may  be  artificially  inflated  with  air  or  carbonic- 
acid  gas.  For  this  purpose,  the  stomach-tube  is  introduced,  and  air  is 
slowly  pumped  in  with  a  small  hand-pump  or  a  Politzer  bag.  Disten- 
tion with  gas  may  be  effected  by  administering  alternately  small  quanti- 
ties of  an  acid  and  an  alkaline  solution,  as  the  two  parts  of  a  Seidlitz 
powder,  until  the  desired  degree  of  distention  has  been  obtained.  The 
latter  method  must  be  used  with  caution,  in  order  not  to  produce  seri- 
ous overdistention,  and  the  stomach-tube  should  be  at  hand  to  relieve 
such  a  condition.  Neither  method  should  be  employed  in  a  case  in  which 
cancer  or  ulcer  is  suspected.  The  stomach  may  be  illuminated  by  means 
of  Einhorn's  electric  bulb  introduced  at  the  end  of  an  esophageal  sound, 
thus  revealing  its  size  and  any  inequality  of  its  surface  due  to  neoplasms. 
The  X-ray  may  also  be  employed  after  filling  the  stomach  with  a  solu- 
tion of  bismuth  subnitrate. 

Palpatmi.—T\\\^  method  is  employed  chiefly  for  the  purpose  of  deter- 
mining the  presence  of  a  tumor.  The  palm  of  the  hand  should  be  slowly 
but  forcibly  pressed  upon  the  surface  and,  by  having  the  patient  relax 
the  abdominal  muscles,  the  neoplasm  can  often  be  felt,  especially  during 
expiration.  A  more  certain  method  is  to  examine  the  patient  in  the 
knee-elbow  position,  with  the  thighs  well  drawn  up.  In  many  cases  the 
size,  location,  outline,  and  firmness  of  the  tumor  may  be  determined,  as 
well  as  the  presence  of  tenderness,  pulsation,  or  fluctuation. 

Percussion  is  of  value  chiefly  in  determining  the  size  of  the  stomach 
and  its  relations  to  other  organs,  particularly  when  it  is  inflated.  The 
presence  of  food  or  fluid  alters  the  result,  especially  along  the  lower 
margin.  Tumors  may  also  be  recognized.  The  normal  percussion  note 
is  tympanitic,  of  rather  high  pitch,  with  more  of  a  metallic  quahty  than 
that  of  the  colon ;  but  it  differs  with  the  degree  of  distention.  Ausculta- 
tory percussion  is  often  more  accurate.  In  order  to  accurately  determine 
the  size  of  the  organ,  percussion  should  be  practiced  first  with  the  stom- 
ach empty,  then  inflated  with  gas,  and  finally  distended  with  water.  It 
is  well  also  to  examine  the  patient  both  in  the  recumbent  and  in  the 
standing  posture. 

Auscultation  is  of  comparatively  little  value  except  in  connection  with 
percussion.    Succussion  may  be  produced  by  shaking  the  patient  or  by 


ACUTE  GASTRITIS  447 

his  voluntary  abdominal  movements,  but  it  affords  only  an  indefinite 
idea  of  enlargement.  The  promptness  with  which  fluid  reaches  the 
stomach  may  also  be  determined  by  auscultation  (deglutition  murmur). 
This  should  normally  occur  six  seconds  after  the  act  of  deglutition,  but 
it  may  be  indefinitely  delayed  when  a  tumor  is  present  at  the  cardiac 
orifice. 

Examination  of  the  Stomach-Contents.     (For  methods  see  p.  719.) 

ACUTE  GASTRITIS. 

SIMPLE  GASTRITIS,   GASTRIC  CATARRH,    ACUTE  DYSPEPSIA. 

Definition.— An  acute  inflammation  of  the  mucous  membrane  of  the 
stomach, 

Etio/ogy.— The  disease  is  exceedingly  frequent  in  all  classes  of  people 
and  at  all  ages,  but  especially  in  childhood.  Many  individuals  are  pre- 
disposed to  it,  and  the  "weak  stomach"  is  not  infrequently  inherited. 
The  idiosyncrasy  may  exist  only  toward  certain  articles  of  food.  The 
gouty  tendency,  chronic  valvular  heart-lesions,  and  hepatic  cirrhosis 
predispose  to  it.  The  same  is  true  of  many  nervous  affections,  mental 
and  physical  fatigue  and  exhaustion,  which  favor  its  occurrence  by  im- 
pairing the  gastric  secretion.  The  disease  is  often  present  at  the  begin- 
ning of  an  acute  infection.  Insufficient  clothing  and  bad  hygienic  sur- 
roundings favor  it,  especially  in  children. 

The  immediate  cause  in  most  instances  is  a  local  irritation,  which  is 
generally  produced  by  errors  in  diet.  The  food  may  be  too  great  in 
quantity,  irritating  or  indigestible  in  quality,  or  taken  at  too  short 
intervals.  When  the  food  is  retained  too  long  in  the  stomach,  as  when 
the  quantity  is  too  great,  it  is  liable  to  undergo  fermentation,  with  the 
production  of  lactic  and  fatty  acids,  and  these  may  be  the  direct  cause  of 
the  inflammation.  Or  the  food,  especially  beef,  fish,  or  milk,  may  have 
undergone  partial  decomposition  before  being  ingested.  Excessive  indul- 
gence in  alcohol,  very  hot  or  very  cold  drinks,  are  also  common  causes. 

Morbid  Anatomy. — The  mucous  membrane  becomes  red,  swollen,  and 
in  places  eroded,  and  it  is  covered  with  mucus.  The  submucosa  is 
edematous,  and  small  hemorrhages  may  occur  in  it.  The  cells  of  the 
gastric  tubules  undergo  cloudy  swelling,  and  there  is  often  a  small-celled 
infiltration  between  the  tubules.  The  inflammation  is  most  marked  in 
the  pyloric  region,  and  it  may  extend  into  the  duodenum. 

Symptoms. — The  disease  may  occur  as  a  mild,  afebrile  attack,  or  it 
may  assume  a  severe,  febrile  form.  In  mild  cases  there  is  usually  a  sense 
of  discomfort,  with  flatulent  distention  of  the  abdomen,  followed  by 
thirst,  headache,  depression,  dizziness,  eructations,  nausea,  and  vomiting. 
The  tongue  is  coated  and  there  may  be  an  increased  flow  of  saliva. 
There  is  a  disagreeable  taste,  and  the  breath  becomes  offensive.  Tem- 
porary relief  is  afforded  by  vomiting.  The  vomited  matter  consists  of 
the  food  last  eaten,  and  it  shows  little  change,  although  it  may  have 
remained  in  the  stomach  for  several  hours.  In  children,  diarrhea,  with 
colicky  pains,  commonly  follows ;  in  adults,  constipation  is  more  common. 
Recovery  usually  takes  place  in  twenty-four  hours. 

The  febrile  form  may  set  in  with  a  chill  and  rise  of  temperature  to 


448  PRACTICE  OF  MEDICINE 

102°  or  104°  F.  (39.0° — 40.0°  C.)-  The  affection  has  been  called,  gastric 
fever.  Lebert  described  a  special,  infectious  form  which  occurred  epi- 
demically. The  tongue  is  broad,  pale,  and  covered  with  a  heavy  coat. 
The  breath  is  foul.  Thirst  becomes  extreme,  and  the  appetite  is  lost. 
The  abdomen  is  distended,  and  there  is  often  tenderness  in  the  epigas- 
trium. Vomiting  is  almost  always  present,  and  it  may  be  persistent,  even 
water  being  ejected.  At  first  only  food  is  brought  up,  then  a  bile-stained 
fluid  containing  much  mucus.  HCl  is  absent,  and  lactic  and  fatty  acids 
are  often  abundant.  Constipation  is  generally  present  in  the  beginning, 
but  it  may  give  place  to  diarrhea.  An  eruption  of  herpes  occasionally 
appears  on  the  lips.  The  urine  is  concentrated,  the  urates  increased,  and 
indican  is  sometimes  present.  The  disease  ordinarily  subsides  after  from 
three  to  five  days,  but  it  may  pass  into  a  subacute  or  chronic  form. 

Diagnosis. — Mild  cases  are  recognizable  without  difficulty.  The  severe 
attack  may,  however,  prove  to  be  an  initial  sym.ptom  of  one  of  the 
infectious  diseases,  especially  in  young  children.  When  there  is  high  fever 
and  much  headache,  the  presence  of  meningitis  is  often  suggested.  Ex- 
cessive pain  may  arouse  suspicion  of  biliary  colic,  but  the  pain  is  not 
over  the  gall-bladder.  The  short  duration  of  the  attack  or,  on  the 
other  hand,^  the  appearance  of  other  symptoms  soon  removes  all  uncer- 
tainty. Typhoid  fever  may  be  excluded  by  the  sudden  onset  and  rapid 
rise  of  temperature,  without  epistaxis,  bronchitis,  or  other  prodromes. 

Treatment. — Mild  cases  generally  recover  in  a  day  without  treatment. 
It  is  well,  however,  to  administer  a  mild  purge,  calomel  or  castor  oil, 
to  remove  decomposed  food  that  may  remain  in  the  intestine.  In  severe 
cases  the  vomiting  should  not  be  too  speedily  arrested.  If  vomiting  does 
not  occur,  it  sKould  be  induced  by  the  administration  of  warm  salt 
water  or  ipecacuanha,  or  by  apomorphin  hypodermically  administered. 
The  patient  should  abstain  from  food  as  much  as  possible  for  a  day  or 
two.  The  eructation  and  nausea  may  be  relieved  with  the  aromatic 
spirit  of  ammonia,  or  sodium  bicarbonate  and  bismuth,  each  gr.  v  (0.3), 
with  a  drop  of  oil  of  anise  or  peppermint  in  each  powder.  If  a  free 
diarrhea  does  not  develop,  a  dose  of  calomel  (gr.  iij — ^v;  0.2 — 0.3) 
should  be  given  in  the  evening,  and  a  Seidlitz  powder  or  calcined  mag- 
nesia in  the  morning. 

PHLEGMONOUS  OR  SUPPURATIVE  GASTRITIS. 

This  is  a  rare  form  of  gastritis  in  which  a  suppurative  inflammation 
occurs  in  the  submucous  and  muscular  coats  of  the  stomach. 

Etiology. — Idiopathic  cases  have  been  observed,  but,  as  a  rule,  the 
disease  is  a  complication  of  one  of  the  septic  infections,  notably  puer- 
peral sepsis  or  pyemia.  The  suppurative  process  may  be  diffused 
throughout  the  wall  of  the  stomach,  or  it  may  be  localized.  In  the 
former  condition  the  pus  is  discharged  either  into  the  stomach  or  into 
the  peritoneal  cavity;  in  the  latter,  abscesses  are  formed. 

Symptoms. — The  case  has  the  appearance  of  an  extremely  severe, 
acute  gastritis,  with  the  addition  of  septic  manifestations.  Frequent 
chills  and  hyperpyrexia  are  commonly  present,  with  a  rapid,  feeble  pulse, 
abdominal  tenderness,  and  diarrhea.  The  diagnosis  is  seldom  made  dur- 
ing life,  but  the  localized  abscess  can  possibly  be  recognized  by  physical 


TOXIC  GASTRITIS  449 

examination,  and  in  the  diffused  form  pus  may  be  found  in  the  vomited 
matter.  The  patient  generally  passes  into  a  delirium,  or  a  coma  from 
which  he  does  not  arouse,  and  death  is  an  event  of  but  a  few  days.  The 
disease  occasionally  assumes  a  more  chronic  course. 

Treatmenf. — Nothing  can  be  done  to  arrest  the  disease.  Morphin 
should  be  given  at  short  intervals  to  relieve  the  suffering. 

TOXIC   GASTRITIS. 

A  severe  inflammation  of  the  stomach,  often  attended  with  great 
destruction  of- tissues,  as  a  result  of  the  ingestion  of  irritating  sub- 
stances, especially  the  corrosive  acids  and  alkalis,  or  arsenic,  antimony, 
phosphorus,  alcohol,  and  other  noncorrosive  poisons. 

Morbid  Anaiomy. — The  corrosive  poisons  produce  a  charred  appear- 
ance of  the  mucous  membrane,  with  complete  destruction  of  vitality,  over 
a  greater  or  less  area.  When  the  quantity  of  poison  taken  has  been 
large,  immediate  perforation  of  the  stomach-wall  may  be  produced.  If 
death  do  not  occur  within  a  few  hours,  an  intense  hyperemia  develops 
around  the  necrotic  areas,  and  hemorrhages  and  transudation  of  serum 
and  round  cells  occur  in  the  submucosa.  Granulation  may  begin,  yet 
perforation  may  occur  after  several  days,  producing  a  rapidly  fatal  gen- 
eral peritonitis. 

The  noncorrosive  poisons  produce  hyperemia  with  hemorrhages  and 
cellular  infiltration  into  the  submucosa,  with  fatty  degeneration  of  the 
gland-cells.  Healing  is  effected  by  cicatrization,  and  stricture  or  hour- 
glass contraction  is  occasionally  produced  as  a  late  result.  Atrophy  of 
the  stomach  and  ulcers  are  possible  results. 

Symptoms. — There  is  generally  intense  pain  and  burning  in  the  epi- 
gastrium; it  may  extend  from  the  mouth  to  the  stomach,  and  there  is 
constant  vomiting  or  retching.  Blood  may  be  vomited,  and  later  frag- 
ments of  the  slough  may  be  ejected.  The  abdomen  becomes  distended, 
tender,  and  painful.  The  urine  is  scant  and  albuminous  or  bloody. 
Petechiae  sometimes  appear  in  the  skin.  Collapse  occurs  in  most  cases 
immediately  after  the  poison  has  been  ingested;  the  pulse  is  then  feeble 
and  the  surface  is  bathed  in  a  cold  sweat.  Convulsions  often  supervene, 
and  death  may  occur  within  a  few  hours,  or  only  after  several  days. 
Recovery  is  possible  when  the  quantity  of  poison  has  been  moderate  or 
when  treatment  has  been  promptly  instituted.  The  diagnosis  is  not  usu- 
ally difficult,  for  the  characteristic  burns  are  generally  to  be  found  in  the 
mouth,  or  the  poison  may  be  recognized  in  the  vomited  matter. 

Treatmenf. — In  poisoning  with  acids,  magnesia  should  be  immediately 
given  with  milk,  egg-albumen,  flour  paste,  or  oil.  In  alkali-poisoning, 
lemon-juice,  vinegar,  a  dilute  mineral  acid,  or  cream  of  tartar  should  be 
given.  When  the  case  is  seen  early,  the  stomach  should  be  thoroughly 
irrigated.    Morphin  should  then  be  administered  for  the  pain. 

Membranous  Gastritis. — This  is  a  rare  form  of  gastric  disease  which 
has  generally  been  met  with  in  diphtheria,  typhoid  or  typhus  fever, 
variola,  or  pneumonia.  A  diffused  or  circumscribed  membranous  exudate 
is  formed  in  which  are  found  the  Klebs-Lofiler  bacilli  or  the  pyogenic 
micro-organisms.  Portions  of  the  fidse  membrane  are  sometimes  vomited; 
otherwise  the  condition  is  seldom  recognized  during  life. 
29 


45  o  PRACTICE  OF  MEDICINE 

Mycotic  and  Parasitic  Gastritis.— Fungi,  especially  the  saccharomyces 
and  sarcinae,  in  one  case  that  of  favus;  anthrax  bacilli;  trichinae,  and 
the  larvae  of  insects  have  been  recognized  as  causes  of  acute  gastritis  in 
a  few  cases.     Tuberculosis  and  syphilis  rarely  attack  the  stomach. 

CHRONIC    GASTRITIS. 

CHRONIC  GASTRIC  CATARRH,  CHRONIC  OR  FLATULENT  DYSPEPSIA,  ATRO- 
PHY OF  THE  STOMACH. 

Definition. — A  chronic  inflammation  of  the  stomach  characterized  by 
changes  in  the  gastric  juice,  increased  secretion  of  mucus,  weakening  of 
muscular  power,  and  the  symptoms  of  chronic  dyspepsia  (Pepper). 

Etiology. — Local  Influences. — In  a  majority  of  cases  the  disease  can 
be  traced  to  repeated  attacks  of  acute  indigestion  or  to  a  more  or  less 
constant  irritation  of  the  stomach  by  improper  food.  The  food  may  be 
indigestible  in  character  or  it  may  be  rendered  so  by  improper  cooking. 
Many  cases  are  to  be  attributed  to  the  constant  use  of  fried  food,  hot 
bread,  pie,  confections,  or  too  highly  seasoned  articles.  Either  the  fat 
or  the  carbohydrates  may  be  in  too  great  quantity.  Eating  at  unsea- 
sonable hours,  or  at  too  short  or  irregular  intervals,  and  eating  too 
rapidly,  without  proper  mastication,  are  among  the  more  frequent  causes. 
The  excessive  use  of  cofl'ee  or  tea  or  drinking  ice-water  during  or  after 
meals  may  gradually  induce  the  disease.  A  chronic  gastric  catarrh  al- 
most always  accompanies  cancer,  ulcer,  and  dilatation.  It  may  be  pro- 
duced also  by  obstruction  of  the  portal  or  general  venous  circulation  as 
a  result  of  cirrhosis  of  the  liver,  valvular  disease  of  the  heart,  and  chronic 
interstitial  disease  of  the  lungs,  or  the  pressure  of  tumors  or  abscesses. 
Other  local  causes  are  the  prolonged  use  of  irritating  drugs  and  nos- 
trums, as  the  mineral  acids,  arsenic,  or  "bitters";  the  drinking  of  liquors 
before  meals,  and  the  excessive  use  of  tobacco.  To  what  extent  the  dis- 
ease may  be  caused  by  the  adulteration  of  food  has  not  yet  been  de- 
termined. 

General  Influences. — An  important  part  in  the  production  of  the  dis- 
ease is  often  played  by  anemia,  chlorosis,  gout,  tuberculosis,  nephritis, 
diabetes,  uterine  disease,  and  many  other  affections. 

Morbid  Anatomy. — The  lesions  are  generally  studied  under  two  heads, 
those  of  simple  chronic  gastritis,  and  those  of  an  interstitial  or  sclerotic 
character ;  but  the  two  forms  usually  represent  an  earlier  and  later  stage 
in  the  same  pathological  process. 

Simple  Chronic  Gastritis.— The  stomach  is  usually  much  enlarged  and 
all  of  its  layers  may  be  thickened.  The  mucous  membrane  is  pale  and 
covered  with  a  heavy  coating  of  tenacious  mucus.  The  veins  stand  out 
prominently  in  cases  associated  with  retarded  circulation,  and  there  may 
be  ecchymoses  or  small  hemorrhages  into  the  mucosa  or  submucosa, 
especially  in  the  pyloric  region,  where  the  disease  is  usually  most  pro- 
nounced. In  a  large  class  of  cases,  often  described  separately,  the  most 
pronounced  feature  is  the  large  quantity  of  tenacious  mucus  which  covers 
the  mucous  membrane,  especially  in  the  vicinity  of  the  pylorus.  The 
mucous  membrane  in  this  region  also  appears  mammillated  or  wrinkled 
in  many  instances,   on  account  of  the  increase  of  connective  tissue  and 


CHRONIC  GASTRITIS  451 

beginning  contraction.    The  condition  has  been  described  as  gastritis 
polyposa,  and  by  French  writers  as  the  etat  mamelonne. 

On  microscopic  examination,  the  glands  appear  enlarged  and  saccular ; 
sometimes  they  are  converted  into  little  cysts  as  a  result  of  obstruction 
of  their  mouths  with  desquamated,  degenerated  epithelium.  The  gland- 
cells  are  usually  granular  from  fatty  degeneration,  or  they  may  be  atro- 
phied so  that  the  principal  and  parietal  cells  can  no  longer  be  distin- 
guished. The  tubules  are  often  widely  separated  by  the  new  connective 
tissue.  Ewald  describes  a  condition  in  which  the  inflammation  extends 
down  to  the  base  of  the  glands,  and  the  cells  are  often  in  different  stages 
of  mucoid  degeneration,  but  he  was  able  to  demonstrate  these  changes 
only  in  specimens  which  had  been  placed  in  alcohol  while  they  were  still 
warm. 

Interstitial  or  Sclerotic  Form. — This  form  is  usually  a  late  result  of 
the  catarrhal  process,  and  its  most  distinctive  feature  is  atrophy.  The 
atrophy,  however,  may  affect  the  stomach  as  a  viscus  or  only  its  walls. 
In  general  atrophy  the  organ  sometimes  becomes  so  small  that  it  will 
hold  only  an  ounce  or  two  of  fluid,  while  its  walls  may  be  greatly  thick- 
ened. It  is  often  referred  to  as  cirrhosis,  or,  better,  sclerosis  ventriculi. 
In  the  other  condition,  the  stomach  as  a  whole  may  be  much  dilated, 
but  the  walls  become  extremely  thin.  In  the  former,  the  wall  of  the 
stomach  may  be  an  inch  thick;  in  the  latter,  it  may  be  less  than  an 
eighth  of  an  inch.  In  extreme  cases  the  mucous  membrane  is  often  so 
atrophic  that  it  is  impossible  to  find  a  vestige  of  gland  tissue  in  it,  but 
cysts  formed  from  the  tubules  may  remain.  The  mucous  surface  is 
smooth  and  firm,  almost  cicatricial  in  appearance.  The  muscular  coat 
may  be  hypertrophied,  or  it  may  be  largely  replaced  by  connective  tissue. 
There  may  be  associated  with  the  lesions  of  the  stomach  a  proliferative 
peritonitis,  perihepatitis,  and  perisplenitis.    Ascites  is  often  present. 

Symptoms. — Symptoms  more  or  less  closely  conforming  to  those  of 
acute  gastritis  usually  occur  at  longer  or  shorter  intervals  in  the  chronic 
form,  and  there  are  often  abnormal  sensations  in  the  throat,  and  motor 
phenomena  which  produce  rumbling  noises,  eructations,  and  possibly 
vomiting.  The  ingestion  of  a  small  quantity  of  food  produces  a  feeling 
of  satiety,  fullness,  and  pain,  or  even  disgust  and  nausea;  and  violent 
eructations  may  continue  for  several  hours  afterward  (flatulent  dys- 
pepsia). The  gas  may  be  odorless  or  highly  offensive.  At  a  later  period 
distress  is  experienced  when  the  stomach  is  empty  as  well  as  when  it  is 
full,  and  eating  no  longer  produces  satiety.  When  the  stomach  is  greatly 
reduced  in  size,  the  food  may  be  too  rapidly  carried  into  the  intestine, 
and  intestinal  catarrh  may  be  set  up.  The  tongue  is  generally  heavily 
coated,  but  the  tip  and  edges  may  remain  intensely  red.  A  catarrhal  or 
aphthous  stomatitis  is  sometimes  observed.  Thirst  often  becomes  most 
annoying,  and  the  patient  craves  sour  or  highly  seasoned  and  indigestible 
articles  of  food.  The  salivary  and  pharyngeal  secretions  are  much  in- 
creased, and  these  in  turn  aggravate  the  nausea.  The  so-called  stomach 
cough,  which  is  not  infrequently  present,  is  probably  due  to  the  catarrhal 
condition  of  the  pharynx.  Morning  nausea  and  vomiting  or  retching 
are  common  symptoms,  especially  in  old  topers.  Very  often  only  bile- 
stained  mucus  is  brought  up.  Vomiting  may  occur  also  with  regularity 
either  immediately  after  meals  or  several  hours  later;  yet  in  some  cases 


452  PRACTICE  OF  MEDICINE 

it  is  absent,  although  the  patient  may  desire  it  as  a  means  of  rehef. 
Acid  eructations  (pyrosis)  frequently  accompany  the  belching.  The  acid 
fluid  thus  brought  up  may  be  in  part  retained  in  the  lower  end  of  the 
esophagus  and  cause  pain  in  the  region  of  the  heart,  known  as  cardialgia 
or  heartburn. 

Digestion  becomes  slow,  and  there  is  often  little  or  no  indication  of 
digestion  when  vomiting  occurs  several  hours  after  a  meal  or  if  the 
contents  are  \vithdrawn  as  late  as  six  or  seven  hours  after  the  ingestion 
of  food.  Abnormal  fermentation  is  generally  found  to  have  set  in,  one 
result  of  which  is  a  sour,  disagreeable  odor.  Chemical  examination 
reveals  little  or  no  HCl,  but  a  greater  or  less  quantity  of  lactic,  butyric, 
and  acetic  acids.  When  the  atrophy  of  the  mucous  membrane  has  be- 
come extreme,  the  hydrochloric  acid,  pepsin,  and  rennet  ferment  may  all  be 
absent.  Absorption  is  also  much  delayed  in  most  cases,  so  that  potas- 
sium iodid  does  not  appear  in  the  saliva  for  a  half-hour  or  longer  after 
it  is  taken  into  the  stomach,  or  twice  the  length  of  time  ordinarily  re- 
quired. The  abdomen  often  becomes  much  distended  with  gas,  producing 
pain  and  dyspnea.  Severe  pain  in  the  abdomen  is  not  common,  but  more 
or  less  frequent  attacks  of  colicky  pains  are  experienced,  and  there  is  a 
more  or  less  constant  sense  of  uneasiness.  Constipation  usually  prevails. 
Headache  and  vertigo  are  common,  and  the  patient  often  becomes  morose 
or  melancholic.  The  pulse  is  generally  small ;  it  may  be  slow,  irregular, 
or  intermittent  from  the  irregular  action  of  the  heart  that  is  often  pres- 
ent.    The  motor  function  of  the  stomach  may  not  be  disturbed. 

In  the  extreme  atrophic  form,  the  symptoms  are  variable,  and,  from 
their  severity,  the  rapid  emaciation  and  anemia,  carcinoma  is  often  sus- 
pected, a  diagnosis  which  is  apparently  supported  by  the  discover}^  of  a 
firm  mass  in  the  region  of  the  pylorus.  But  the  mass  is  due  either  to 
the  hypertrophy  of  the  muscular  coat  or  to  the  lamellated  condition  of 
the  mucous  membrane,  and  the  patient  long  outlives  the  limit  of  cancer. 
In  some  cases  the  features  correspond  more  closely  to  those  of  pernicious 
anemia.  The  urine  is  usually  of  dark  color,  high  specific  gravity,  and 
contains  a  large  quantity  of  urates  and  phosphates  and  often  calcium 
oxalate. 

Diagnosis.— Ulcer,  cancer,  dilatation,  and  the  neuroses  must  be  ex- 
cluded before  a  diagnosis  of  chronic  gastritis  can  be  arrived  at.  The 
first  three  of  these  affections  are  ordinarily  accompanied  with  gastritis, 
however,  and  for  this  reason  the  presence  or  absence  of  cancer  in  particu- 
lar cannot  be  determined  in  some  cases  until  the  patient  has  been  under 
observation  for  several  months  and  the  effects  of  treatment  have  been 
observed.  Cancer  is  characterized  by  a  much  more  rapid  progress,  with 
emaciation,  weakness,  and  cachexia,  features  which  are  seldom  so  pro- 
nounced in  an  independent  case  of  chronic  gastritis. 

Treatment — Dietetic. — In  a  case  of  moderate  severity,  before  extreme 
atrophy  has  developed,  it  is  often  unnecessary  to  rigidly  restrict  the  diet. 
It  is  sometimes  sufficient  to  prohibit  the  use  of  certain  articles.  The 
patient  generally  knows  better  than  the  physician  what  kinds  of  food  he 
can  most  easily  digest,  but  he  generally  requires  the  positive  direction 
of  the  physician  to  enable  him  to  control  his  appetite.  Persons  present 
themselves,  also,  who  have  already  reduced  their  dietary  beyond  reason, 
and  these  are  often  benefited  by  a  more  liberal  allowance.    In    other 


CHROXIC  GASTRITIS  453 

cases,  a  cure  can  often  be  effected  by  nothing  more  than  proper  regula- 
tion of  the  food.  Advice  must  generally  be  given  as  to  the  necessity  of 
eating  at  regular  intervals,  the  thorough  mastication  of  the  food,  and  the 
limitation  of  its  quantity.  Hasty  eating  and  overeating  are  the  two 
main  factors  in  the  production  of  chronic  dyspepsia  in  this  country,  and 
the  third  element  in  many  cases  is  the  habit  of  immediately  rushing  back 
to  business  after  a  hasty  meal.  Both  mental  and  physical  exertion 
should  be  postponed,  if  possible,  for  an  hour  after  a  full  meal.  Many 
dyspepsias  are  benefited  by  a  change  of  the  time  of  the  principal  meal  to 
an  hour  at  which  it  can  be  leisurely  eaten  and  followed  by  an  hour's 
rest.  Idiosyncrasy  must  always  be  regarded,  however,  and  the  form  of 
food  which  is  theoretically  best  for  the  patient  may  prove  less  suitable 
than  articles  which  should  not  agree.  A  vast  deal  depends  also  upon  the 
proper  cooking  of  the  food,  and  the  physician  should  be  capable  of 
gi\ang  instruction  in  this  department  of  domestic  economy.  Articles 
fried  in  grease  are  generally  unfit  for  a  healthy  stomach,  much  more  so 
for  one  that  is  inflamed.  In  many  instances  it  is  necessary  to  give  ex- 
plicit written  direction  in  regard  to  the  food  to  be  eaten,  and  that  to  be 
avoided.  In  other  cases,  doing  this  only  converts  despondency  into 
despair  by  impressing  the  patient  too  strongly  with  the  seriousness  of 
his  affliction. 

Albuminoids  generally  agree  best  with  the  stomach.  Those  which  are 
most  easily  assimilated  should  be  chosen  for  a  severe  case.  It  is  often 
advisable  to  begin  the  treatment  by  placing  the  patient  on  an  absolute 
milk  diet;  but  there  are  many  individuals  who  cannot  take  milk.  Some- 
times the  objectionable  feature  can  be  removed  by  the  addition  of  lime- 
water,  Vichy  or  other  alkaline  carbonated  water,  and  a  pinch  of  salt. 
From  two  to  two  and  a  half  quarts  of  milk  should  be  consumed  daily, 
but  it  should  be  taken  in  quantities  of  a  half-pint  or  less  every  two  or 
three  hours.  Skimmed  milk  agrees  better  than  whole  milk  in  some 
cases,  and  some  patients  can  drink  buttermilk  who  cannot  take  sweet 
milk,  but  they  usually  tire  of  it  more  readily.  WTiile  the  patient  is  on 
the  milk  diet  the  stools  should  be  regularly  examined  in  order  to  avoid 
giving  more  of  it  than  can  be  assimilated.  After  a  few  days  on  this 
diet,  especially  if  hunger  is  developed  by  it,  a  soft-cooked  egg,  beef-juice, 
scraped  raw  or  rare  broiled  beef,  and  a  piece  of  toast  or  zwiebach  may 
be  added  to  the  diet  list.  If  it  is  deemed  advisable  to  continue  the  liquid 
diet,  broths,  bouillon,  clear  soups,  junket,  and  gruels  may  be  employed. 
Farinaceous  food  should  generally  be  prohibited  until  the  patient  has 
shown  marked  improvement.  It  is  especially  contraindicated  in  cases  of 
dilatation,  for  it  then  remains  so  long  in  the  stomach  that  fermentation 
occurs  and  intestinal  catarrh  results.  Hot  bread  and  pastry  should  be 
permanently  forbidden.  WTiite  bread  may  generally  be  eaten  in  small 
quantity  if  it  is  not  too  fresh,  or  better  after  it  has  been  toasted.  Only 
a  small  quantity  of  butter  should  generally  be  eaten.  WTien  acid  eructa- 
tions are  produced,  the  bread  should  be  temporarily  discontinued.  The 
same  is  equally  true  of  potatoes,  although  a  mealy  baked  potato  is 
sometimes  well  borne.  Graham  or  brown  bread  or  that  made  from  the 
whole  wheat  agrees  with  some  individuals  better  than  the  white.  Sugar 
should  be  taken  sparingly,  as  a  rule. 

The  behavior  of  the  stomach  toward  fruits  and  green  vegetables  is 


454  PRACTICE  OF  MEDICINE 

very  uncertain,  and  the  permission  of  such  articles  must  be  based  upon 
the  experience  of  the  individual.  Cooked  ripe  fruit  can  generally  be 
eaten,  and  a  baked  apple  is  an  agreeable  addition  to  the  exclusive  milk 
diet.  Young  peas  and  beans  and  stewed  onions  may  prove  digestible, 
but  cabbage,  cauliflower,  corn,  strawberries,  peaches,  bananas,  and  many 
other  fruits  and  vegetables  must,  as  a  rule,  be  forbidden.  Fat  can  seldom 
be  eaten ;  veal,  pork,  and  the  meat  of  any  animal  just  after  it  has  been 
killed  are  difficult  of  digestion.  In  some  cases  a  diet  consisting  almost 
exclusively  of  beef,  roast  or  broiled,  but  always  tender  and  rare  and 
freed  from  its  coarse  fiber,  with  an  occasional  roast  of  mutton  or  broiled 
chops,  proves  the  most  satisfactory.  In  severe  cases,  after  atrophy  of 
the  mucous  membrane,  peptonized  beef  preparations  and  peptonized  milk 
may  be  used  with  advantage^  When  solid  food  is  eaten,  it  is  better  to 
limit  the  quantity  of  fluids.  A  small  quantity  of  soup  may  be  taken  at 
the  beginning  of  a  meal,  but  little  or  no  fluid  should  be  drunk  with  the 
food.  Very  hot  or  very  cold  drinks,  tea,  coff'ee,  and  alcoholic  beverages 
should  generally  be  forbidden.  Finally,  the  patient  should  never  allow 
himself  to  fill  his  stomach;  it  is  much  better  to  stop  before  the  appetite 
has  been  fully  assuaged. 

Hygienic. — A  very  important  factor  in  the  treatment  of  most  cases  is 
the  relief  of  the  morbid  introspection  which  is  generally  present,  with  its 
resultant  despondency  and  melancholy.  When  the  condition  is  very  pro- 
nounced, it  is  often  better  to  have  a  change  of  scene,  a  sojourn  in  the 
mountains  or  a  sea-voyage  in  the  summer,  or  a  visit  to  the  Southern 
resorts  in  the  winter.  It  is  often  better  to  send  the  patient  to  one  of  the 
watering-places  where  the  dietetic  treatment  can  be  carried  out.  Under 
any  circumstances  he  should  take  systematic  exercise  including  walking, 
horseback  riding,  and  outdoor  games.  He  should  always  be  with  cheerful 
companions  who  are  capable  of  holding  his  attention  away  from  himself. 

Medicinal. — The  objects  to  be  attained  by  the  administration  of  drugs 
are  :  (i)  To  supply  the  chemical  elements  of  the  gastric  secretion  which 
are  absent;  (2)  to  restore  the  secretory  and  motor  power;  (3)  to  pre- 
vent abnormal  fermentation;  and  (4)  to  relieve  special  symptoms.  To 
meet  the  first  indication,  dilute  hydrochloric  acid  is  usually  administered 
in  doses  of  TT|,xv  to  xx  (i.o — 1.2)  in  two  or  three  ounces  of  water  imme- 
diately after  meals.  It  should  be  taken  through  a  tube  in  order  to  pro- 
tect the  teeth,  and  the  dose  may  be  repeated  a  few  hours  later  or  when- 
ever a  feeling  of  discomfort  arises.  Pepper  advised  the  administration  of 
quinin  (gr.  j;  0.06)  and  strychnin  (gr.  1-60;  o.ooi)  with  the  acid.  A 
few  grains  of  pepsin  may  be  added  with  benefit  in  some  cases,  but  it  is 
probably  seldom  necessary,  and  much  of  the  pepsin  that  is  dispensed  is 
worthless.  In  cases  of  extreme  atrophy  of  the  mucous  membrane,  when 
the  administration  of  the  acid  fails  to  stimulate  the  secretion  of  pepsin, 
an  active  preparation  should  be  administered.  The  action  of  hydro- 
chloric acid  is  not  uniformly  beneficial.  Pancreatin  in  doses  of  gr.  v  to  x 
(0.30 — 0.60),  with  an  equal  quantity  of  sodium  bicarbonate,  is  often  of 
great  value  when  given  a  half-hour  after  each  meal,  especially  in  mucous 
and  atrophic  cases.  Ptyalin  and  diastase  or  a  good  malt  extract  are 
recommended  by  some  writers  for  the  same  class  of  cases. 

To  increase  the  secretory  and  motor  power  of  the  stomach,  the  gen- 
eral condition  of  the  patient  must  be  treated,  especially  in  the  presence 


DILATATION  OF  THE  STOMACH  455 

of  anemia  or  malnutrition,  or  when  the  condition  is  due  to  venous  ob- 
struction, as  in  connection  with  valvular  disease  of  the  heart  or  hepatic 
cirrhosis.  Lavage  is  usually  the  most  successful  method  of  local  treat- 
ment. (For  the  method,  see  page  719.)  It  should  be  performed  with  a 
large  quantity  of  lukewarm  water,  either  plain  or  containing  i  per  cent 
of  common  salt  or  5  per  cent  of  sodium  bicarbonate.  The  alkaline 
solution  is  especially  indicated  when  much  mucus  is  present.  A  3  per 
cent  solution  of  boric  acid  or  a  very  dilute  carbolic  acid  solution  may 
be  employed  when  there  is  much  fermentation.  The  irrigation  should 
generally  be  continued  until  the  clear  water  returns.  One  treatment 
each  day  is  usually  sufficient,  or  one  in  two  days  if  the  patient  be  weak. 
It  is  best  done  in  the  morning,  when  the  stomach  is  empty,  but  when 
there  is  much  distress  and  flatulency  during  the  night  it  may  be  prac- 
ticed just  before  retiring.  The  relief  is  so  great  that  many  patients  are 
restrained  with  difficulty  from  abusing  the  practice.  In  other  cases, 
however,  the  fear  of  the  tube  is  so  great  that  the  method  cannot  be 
satisfactorily  employed,  or  the  patient  positively  and  persistently  refuses 
to  submit  to  it.  In  such  cases  the  same  object  may  often  be  attained, 
with  almost  as  much  benefit,  from  the  administration  of  sodium  bicar- 
bonate, gr.  XX  to  XXX  (1.3 — 2.0)  in  a  half-pint  (250)  or  more  of  warm 
water,  twenty  minutes  before  each  meal.  In  this  way  the  mucus  is  dis- 
solved, and  the  effect  is  much  the  same  as  that  of  lavage.  The  subse- 
quent secretion  of  HCl  is  believed  to  be  increased. 

This  secretion  is  sometimes  improved  by  an  increase  of  the  amount 
of  salt  in  the  food.  The  bitter  tonics  are  also  useful  in  some  cases, 
especially  to  stimulate  appetite,  but  they  sometimes  prove  irritating. 
Strychnin  or  the  compound  tincture  of  gentian  with  nux  vomica  may 
be  prescribed. 

One  of  the  most  valuable  remedies  is  the  nitrate  of  silver.  It  is  some- 
times applied  in  solution  through  the  tube,  but,  as  a  rule,  it  is  admin- 
istered in  pills  containing  also  the  extract  of  belladonna  and  perhaps 
nux  vomica.  It  should  be  given  when  the  stomach  is  empty,  as  a  half- 
hour  before  mealtime.  A  record  of  the  quantity  administered  should 
always  be  kept,  in  order  to  avoid  the  production  of  argyria.  The  first 
indication  of  this  condition  is  a  dark  line  on  the  gums. 

Electricity  has  proved  beneficial  in  some  cases.  A  mild  faradic  current 
is  applied  through  Einhorn's  electrode  after  the  stomach  has  been  mod- 
erately distended  with  water.  Many  other  remedies  have  been  recom- 
mended— among  them,  creosot,  carbolic  acid,  magnesia,  animal  charcoal, 
bismuth  subgallate,  sahcylic  acid,  chloroform,  and  the  essential  oils— for 
the  relief  of  acid  fermentation  and  flatulency.  For  nausea  and  vomiting, 
the  dilute  hydrocyanic  acid,  three  drops;  serium  oxalate,  camphorated 
tincture  of  opium  or  cocain,  gr.  Ys  (0.008),  may  be  given.  The  regular 
action  of  the  bowels  must  be  secured  by  laxatives. 

DILATATION  OF  THE  STOMACH. 

GASTRECTASIA,   GASTRECTASIS. 

Definition. — An  acute  or  chronic  enlargement  of  the  stomach,  with  re- 
laxation and  weakness  of  its  walls.    The  term  megast7-ia  is  applied  to  the 


4s6  PRACTICE  OF  MEDICINE 

condition  in  which  the  stomach  is  abnormally  large,  but  still  capable  of 
discharging  its  contents  into  the  duodenum. 

Etiology. — Acute  dilatation  is  rare,  in  this  country  at  least,  and  usu- 
ally results  from  a  too  hasty  ingestion  of  an  enormous  quantity  of  food 
or  drink;  occasionally  from  the  rapid  evolution  of  gas.  The  sudden 
dilatation  produces  a  paralytic  condition  of  the  walls,  which  sometimes 
proves  fatal. 

Chronic  dilatation  may  occur  at  any  time  of  life,  but  it  is  more  frequent 
in  men  of  middle  age,  especially  in  beer-drinkers.  It  is  not  uncommon, 
also,  in  rachitic  children.  The  principal  causes  are  narrowing  or  obstruc- 
tion of  the  pylorus  or  duodenum,  and  deficiency  of  muscular  power. 

(dt)  Narrowing  of  the  pylorus  is  seen  in  the  rare  congenital  stricture 
and  as  a  result  of  cancer,  the  cicatrization  following  ulcer,  toxic  or 
phlegmonous  gastritis.  It  is  produced  also  by  the  nonmalignant  hyper- 
plastic thickening  of  the  pylorus  in  chronic  gastritis.  Among  the  other 
recognized  causes  are  pressure  from  without,  by  tumors,  rarely  by  a 
floating  kidney ;  or  obstruction  from  within,  as  by  polypi.  A  sharp  bend 
or  twist  caused  by  adhesions  to  the  liver  or  gall-bladder  or  by  the 
dragging  weight  of  a  distended  stomach  (volvulus  of  the  stomach)  has 
been  observed  in  a  few  instances.  Obstruction  by  foreign  bodies,  as 
balls  of  hair,  or  coins,  has  been  the  cause  in  some  cases. 

(^P)  Deficiency  of  muscular  power  may  result  from  habitual  overfilling 
of  the  stomach  with  food  and  drink  or  from  atony  of  the  muscle  due  to 
malnutrition  in  the  course  of  such  diseases  as  chronic  gastritis,  anemia, 
tuberculosis,  or  cancer,  or  following  nervous  exhaustion  or  an  acute 
infection,  as  typhoid  fever.  It  may  follow  degeneration  of  the  muscle 
occasioned  by  amyloid  disease,  constipation,  or  peritonitis;  and  hernia 
has  been  named  as  a  cause  which  might  operate  through  restraining 
the  movements  of  the  stomach. 

Morbid  Anatomy.— The  degree  of  dilatation  is  exceedingly  variable. 
Extreme  cases  have  been  reported  in  which  the  stomach  held  from  i  o  to 
1 6  pounds  of  fluid.  When  the  dilatation  is  moderate,  there  may  be  com- 
pensatory hypertrophy  of  its  walls ;  but  when  it  is  extreme  or  of  long 
duration,  the  walls  become  thin  through  stretching  and  atrophy.  The 
greatest  dilatation  is  found  in  the  fundus,  and  the  greater  curvature 
sometimes  sinks  two  or  three  inches  below  the  umbilicus.  Gastroptosia, 
or  downward  displacement  of  the  entire  stomach,  may  accompany  the 
dilatation,  and  the  right  kidney  is  sometimes  displaced  downward.  The 
mucous  membrane  is  usually  hyperemic  and,  on  microscopic  examination, 
shows  atrophy  of  the  secretory  glands,  as  it  does  in  chronic  gastritis. 

Symptoms.— The  clinical  manifestations  vary  greatly  with  the  severity 
of  the  disease  and  the  nature  of  its  cause.  Symptoms  are  ordinarily 
present  which  resemble  closely  those  of  an  aggravated  chronic  gastritis. 
There  is  a  feeling  of  fullness  or  distress  in  the  stomach,  with  epigastric 
tenderness,  especially  after  eating.  Large  quantities  of  gas  and  sour 
fluid  are  eructated.  The  appetite  is  variable,  sometimes  ravenous;  the 
tongue  is  heavily  coated  and  the  breath  is  usually  foul.  The  most  nearly 
pathognomonic  symptom,  however,  is  periodic  vomiting.  This  may  occur 
several  times  a  day  in  the  beginning,  but  as  the  dilatation  increases  it 
becomes  less  frequent  until  it  occurs  only  at  intervals  of  two  or  three 
days,  and  an  enormous  quantity  of  food,  liquid,  and  gas  is  brought  up. 


DILATATION  OF  THE  STOMACH  457 

As  much  as  a  gallon  (4  liters)  is  sometimes  vomited  at  one  time.  The 
vomited  matter  is  generally  frothy,  from  abnormal  fermentation,  and  it 
has  a  characteristically  sour  odor.  It  separates,  on  standing,  into  three 
layers.  The  lowest  contains  the  food,  the  middle  a  dark  gray  turbid 
fluid,  and  the  upper  a  brownish  froth.  HCl  is  often  absent,  but  it  may 
be  present  in  normal,  increased,  or  diminished  quantity.  Lactic,  butyric, 
and  acetic  acids  and  various  gases,  especially  hydrogen  sulphid  and 
marsh  gas,  are  present.  Different  molds  and  bacteria,  the  yeast  fungus 
and  sarcina  ventriculi,  are  found  on  microscopic  examination.  Constipa- 
tion results  from  the  obstruction  to  the  passage  of  food  and  fluid  into 
the  intestine;  and  anemia  and  emaciation,  with  marked  dryness  of  the 
skin,  commonly  follow.  When  the  stomach  finally  becomes  unable  to  con- 
tract with  sufficient  force  to  discharge  its  contents  through  vomiting, 
the  patient's  discomfort  is  extreme.  The  abdomen  becomes  so  much  dis- 
tended that  he  cannot  lie  down  with  comfort,  and  the  nausea  and  gase- 
ous eructations  become  almost  constant.  The  absorption  of  the  products 
of  decomposition  gives  rise  to  such  nervous  phenomena  as  numbness, 
vertigo,  and  insomnia;  tetany  and  epileptiform  spasms  may  be  induced. 
Fat-necrosis  has  been  reported  in  at  least  one  instance,  probably  as  a 
result  of  pressure  on  the  pancreas. 

Physical  Examinaiion. — Inspection.^T\i&  outline  of  the  dilated  stom- 
ach is  often  distinctl}^  visible,  especially  after  artificial  distention.  The 
greatest  prominence  is  in  the  left  h3'pochondrium,  and  below  the  um- 
bilicus when  the  patient  is  standing,  but  the  epigastrium,  right  hypo- 
chondrium,  and  umbilical  regions  are  prominent.  The  peristaltic  move- 
ment from  left  to  right  can  sometimes  be  observed,  and  rarely  there  is  a 
reversed  peristalsis. 

Palpation, — A  tumor-like  thickening  in  the  region  of  the  pylorus  can 
often  be  felt  in  the  nonmalignant  as  well  as  in  cancerous  cases.  The 
sensation  obtained  from  pressure  on  the  stomach  is  peculiar  and  not 
unlike  that  of  palpating  an  air-cushion.  A  splashing  sound  which  can  be 
heard  at  some  distance  (clapotage)  may  often  be  produced  through 
bimanual  examination  or  by  shaking  the  patient.  It  is  significant  of 
dilatation  only  when  it  can  be  elicited  several  hours  after  a  meal.  The 
gurgling  of  gas  passing  through  the  pylorus  can  sometimes  be  felt. 

Percussion. — The  outline  of  the  stomach  can  be  accuratel}^  mapped  out 
by  this  method,  but  the  examination  should  be  repeated  with  the  patient 
in  different  positions,  in  order  to  avoid  error  in  the  lower  boundary. 
This  can  be  more  definitely  made  out  with  the  patient  hang  on  his  back. 
The  percussion  note  is  tympanitic  and  rather  high-pitched  when  the 
stomach  is  distended  with  gas  or  air,  but  flat  when  distended  with  water. 
The  latter  method  of  distention  is  of  little  value  for  determining  the 
outline. 

Auscultation  is  of  limited  service.  The  succussion  sound  may  be 
readily  determined  in  most  cases,  but  it  is  not  of  much  value.  A  fine 
sizzling  sound  can  sometimes  be  heard,  which  is  believed  to  be  due  to  the 
evolution  of  gas  in  the  decomposition  of  the  food,  since  the  same  sound 
can  be  heard  after  the  administration  of  an  effervescent  powder.  \Mien 
the  stomach  is  distended  with  gas,  the  heart-sounds  are  transmitted  with 
unusual  distinctness  and  they  often  have  a  metallic  quality.  Auscultatory 
percussion  also  aftbrds  an  accurate  means  of  determining  the  outline. 


458  PRACTICE  OF  MEDICINE 

Diagnosis. — This  is  usually  quite  simple.  It  is  based  upon  :  (a)  The 
periodical  vomiting,  ((^)  the  enormous  quantity  ejected,  (r)  the  gaseous 
eructations,  and  (/)  the  enlarged  outlines  of  the  distended  stomach. 
The  condition  cannot  well  be  mistaken  for  any  other,  although  some  re- 
markable blunders  have  been  recorded.  In  gastroptosia  the  stomach  is 
displaced  downward  and  may  be  somewhat  enlarged,  but  the  food  does 
not  stagnate  in  it,  and  vomiting  is  not  present.  In  megastria  the  en- 
largement in  not  strictly  pathological,  since  the  stomach  is  capable  of 
performing  its  normal  function. 

Prognosis. — The  prognosis  is  hopeless  in  a  case  due  to  cancer,  and 
very  unfavorable  in  other  forms  of  stenosis.  When  the  condition  is  due 
to  overdistention  with  food  and  drink  or  to  chronic  gastritis,  and  pro- 
viding that  it  is  not  extreme,  great  benefit  can  be  obtained  from  treat- 
ment, but  it  is  seldom  possible  to  control  the  patient's  habits  outside  of 
a  hospital.  The  results  of  surgical  methods  in  nonmalignant  stenosis 
have  been  brilliant  in  some  cases. 

Treatment. — This  comprises  relief  from  the  source  of  distention 
through  removal  of  the  fermenting  stomach-contents.  The  best  means  of 
accomplishing  this  is  lavage.  The  second  object  is  to  increase  the  mus- 
cular power  of  the  organ,  and  the  third  to  select  the  most  suitable  diet 
for  the  patient. 

(^a)  Lavage  is  not  only  the  most  useful  method,  but  it  has  its  great  ■ 
est  field  of  usefulness  in  this  condition.  By  it  the  weight  of  the  accumu- 
lating food  is  removed  from  the  stomach,  and  the  expansive  force  of  the 
gases  developed  in  it  is  taken  away.  At  the  same  time  the  mucous  mem- 
brane is  cleansed  and  disinfected,  and  any  ptomains  or  toxins  that  may 
have  been  formed  are  gotten  rid  of.  (For  the  method  of  lavage,  see 
page  719.)  The  stomach  should  generally  be  washed  out  once  a  day, 
but  in  extreme  cases  it  may  be  done  twice.  It  is  customary  to  use  luke- 
warm water  or  an  alkaline  or  antiseptic  solution.  The  reduction  of  size 
obtained  in  a  few  weeks  is  sometimes  remarkable.  The  patient  can 
generally  be  taught  to  use  the  tube  without  assistance. 

((^)  To  increase  the  muscular  power,  strychnin  is  the  best  remedy.  A 
tablet  containing  gr.  1-30  (0.002)  should  be  given  three  or  four  times 
daily.  Iron  and  ergot  are  also  of  benefit  in  some  cases.  The  faradic 
current  may  be  applied  through  the  Einhorn  electrode  introduced  into 
the  stomach,  the  opposite  pole  being  applied  to  the  epigastrium.  E.  G. 
Marshall  has  obtained  better  results  by  applying  a  large  sponge  elec- 
trode to  the  epigastrium,  and  a  smaller  one,  connected  to  the  same  pole 
by  means  of  a  V-shaped  cord,  to  the  neck,  over  the  course  of  the  pneu- 
mogastric  nerve.  The  wearing  of  an  elastic  abdominal  band  is  a  source 
of  relief  from  the  dragging  weight. 

(r)  Diet.— The  important  indication  is  to  administer  the  food  in  a 
concentrated  form,  in  order  not  to  produce  distention  or  downward  trac- 
tion. The  food  must  be  of  a  character  that  will  not  produce  gaseous 
dilatation.  It  should  be  taken  in  small  quantities  at  short  intervals. 
In  the  beginning,  it  should  consist  principally  of  raw  or  rare  broiled  or 
roast  beef  and  other  tender  meats;  soft  eggs  with  a  little  toasted  bread 
or  zwiebach.  Very  httle  fluid  should  be  taken;  the  milk  diet  is  con- 
traindicated.  Water  may  be  drunk  an  hour  before  each  meal,  or  in  the 
morning  upon  rising,  and  before  retiring  at  night,  but  not  with  the  meal. 


PEPTIC  ULCER  459 

After  the  size  of  the  stomach  has  been  considerably  reduced  by  treat- 
ment, thoroughly  cooked  vegetables  may  be  carefully  added  to  the  diet- 
list.  In  cases  of  stenosis  that  are  known  to  be  nonmalignant,  and  in 
those  that  are  doubtful,  the  resort  to  surgical  means  of  diagnosis  and 
treatment  should  not  be  too  long  delayed,  for  a  condition  has  not  in- 
frequently been  revealed  upon  the  post-mortem  table  that  might  have 
been  remedied.  The  principal  methods  will  be  found  in  the  works  on 
surgery,  under  the  heads  of  Loreta's  method  of  digital  dilatation  of  the 
pylorus,  gastroenterostomy,  and  pylorectomy. 

PEPTIC  ULCER. 

SIMPLE,  ROUND,  PERFORATING,  OR  RODENT  ULCER  OF  THE  STOMACH. 

Definition. — A  round  or  oval,  usually  single,  sharply  defined  loss  of 
tissue  caused  by  the  digestive  action  of  the  gastric  juice  on  a  portion  of 
the  mucous  membrane  of  the  stomach  or  of  the  duodenum  whose  nutri- 
tion has  been  impaired.  The  process  of  its  formation  is  one  of  necrosis 
rather  than  of  ulceration. 

Etiology. — Two  factors  are  generally  regarded  as  operative  in  the 
production  of  the  so-called  ulcer ;  first  an  impairment  of  the  nutrition  of 
a  small  portion  of  the  mucous  membrane,  second  the  action  upon  this 
area  of  a  superacid  gastric  juice,  favored,  perhaps,  by  an  alteration  in 
the  composition  of  the  blood.  The  disturbance  of  nutrition  is  probably 
due  to  such  vascular  change  as  the  plugging  of  a  small  blood-vessel, 
through  thrombosis  or  embolism,  or  to  a  diminished  circulation  in  the 
vessels.  The  interference  may  be  caused  by  mechanical  or  thermal  irri- 
tation of  the  mucous  membrane,  as  by  blows  or  pressure  upon  the 
epigastrium  or  by  hot  food.  The  embolus  may  originate  in  a  diseased 
heart,  or  it  may  consist  of  bacteria  which  have  gained  entrance  to  the 
circulation.  And,  since  duodenal  ulcer  frequently  follows  burns,  it  has 
been  suggested  that  an  embolus  may  be  caused  by  such  injury.  The 
superacidity  of  the  gastric  fluid  is  regarded  by  some  writers  as  a  result 
of  the  ulcer.  If  not  active  in  its  production,  it  doubtless  retards  its 
heahng.  Cystic  dilatation  of  Brunner's  glands  has  been  suggested  also 
as  a  cause  of  the  duodenal  ulcer.  It  is  probable  that  more  than  one  of 
these  causes  is  operative  in  most  cases.  It  is  also  highly  probable  that 
the  true  cause  of  many  cases  remains  to  be  discovered. 

Age  and  ^^x.— Gastric  ulcer  is  about  twice  as  common  in  women  as 
in  men.  In  women  it  generally  occurs  between  the  ages  of  20  and  30, 
in  men  between  30  and  40.  It  is  not  infrequent  in  children  and  old 
persons,  and  it  has  been  found  in  the  fetus  and  new-born  infant.  It  is 
doubtless  more  common  than  is  usually  recognized.  Heredity  is  thought 
to  be  a  causative  influence  in  some  instances.  Ulcer  of  the  duodenum 
is  more  frequent  in  men. 

Occ7ipatio7i  IS  an  important  factor,  since  the  disease  is  very  frequent 
among  servant  girls  and  cooks,  probably  as  a  result  of  improper  food 
and  consequent  anemia;  and  in  shoemakers  and  tailors,  as  a  result  of 
pressure  over  the  stomach.  The  history  of  such  injury  as  a  blow  is  often 
obtained. 

Anemia  and  chlorosis  are  recognized  as    frequent    causes,   operating, 


46o  PRACTICE  OF  MEDICINE 

perhaps,  by  reducing  the  acidity  of  the  blood,  or  in  some  other  way 
impairing  the  power  of  the  mucous  membrane  to  resist  the  action  of  the 
gastric  juice.  Such  affections  as  tuberculosis,  syphilis,  disease  of  the 
heart  or  liver,  and  arteriosclerosis  have  been  regarded  as  favoring  the 
production  of  gastric  ulcer. 

Morbid  Anatomy.  — The  ulcer  is  usually  single,  but  a  large  number  (in 
one  case  34)  have  been  repeatedly  found.  Several  ulcers  may  coalesce 
to  form  an  irregular  destruction  of  tissue.  They  may  occur  in  any 
region,  but  in  three-fourths  of  the  cases  they  have  been  found  near  the 
pylorus,  generally  on  the  posterior  wall  near  the  lesser  curvature.  In  the 
duodenum  they  are  much  less  frequent  than  in  the  stomach,  and  they  are 
always  found  above  the  biliary  papilla.  Their  diameter  is  usually  about 
y^  inch  (6  mm.),  but  they  may  be. as  large  as  four  or  five  inches  (10. o— 
12.5  cm.).  The  appearance  of  a  recent  ulcer  is  as  though  the  tissue  had 
been  removed  with  a  punch,  so  uniform  and  clean-cut  are  its  edges.  The 
shape  is  that  of  a  truncated  cone,  the  apex  of  which  may  rest  upon  the 
submucous,  muscular,  or  peritoneal  coat.  In  very  acute  cases,  especially 
when  located  in  the  anterior  wall,  the  peritoneum  may  be  perforated, 
with  fatal  general  peritonitis  as  the  inevitable  result.  In  some  instances 
a  sinus  is  formed  which  communicates  with  the  colon,  pleura,  pericar- 
dium, even  with  the  left  ventricle  of  the  heart.  Localized  abscesses 
sometimes  result,  and  when  air  penetrates  these  a  condition  known  as 
subphrenic  pyopneumothorax  is  produced.  In  very  chronic  ulcers  the 
clean-cut  appearance  may  be  lost.  A  striking  feature  is  the  absence  of 
inflammatory  reaction  in  the  vicinity  of  the  ulcer. 

The  scars  of  former  ulcers  are  not  infrequently  discovered,  and  a  recent 
ulcer  is  often  found  in  close  proximity  to  an  old  cicatrix.  Deformities  of 
various  kinds  may  be  produced  by  the  contraction  of  the  cicatrices  of 
large  or  numerous  ulcers.  Hour-glass  contraction  is  occasionally  ob- 
served, but  a  much  more  common  result  is  the  narrowing  of  the  pylorus, 
which  may  lead  to  dilatation.  Deformity  may  result  also  from  the  ad- 
hesions formed  between  the  peritoneum  immediately  over  an  ulcer  and 
a  neighboring  organ,  as  the  liver  or  spleen.  These  adhesions,  however, 
often  prevent  perforation  into  the  peritoneal  cavity.  A  gastrocutaneous 
fistula  is  a  rare,  though  relatively  fortunate,  result  of  perforation.  It 
usually  opens  near  the  umbilicus.  Emphysema  of  the  subcutaneous  cel- 
lular tissue  has  been  observed  as  a  result  of  perforation.  The  erosion 
of  a  blood-vessel  in  the  stomach-wall  produces  hemorrhage,  a  not  un- 
common symptom.  The  hepatic  and  splenic  arteries  and  the  portal  vein 
have  also  been  opened. 

Symptoms.— The  early  symptoms  are  usually  those  of  indigestion, 
with  discomfort  after  eating  and  gaseous  or  acid  eructations.  The  appe- 
tite sometimes  remains  normal,  but  nausea  frequently  develops,  and 
vomiting  may  occur.  The  patient  rapidly  becomes  anemic,  and  the 
dyspeptic  symptoms  gradually  or  suddenly  increase  until  the  discomfort 
becomes  pain.  This  is  usually  limited  to  the  region  of  the  ulcer.  It  may 
be  an  almost  constant,  gnawing  sensation,  but  it  is  generally  sharp.  It 
is  aggravated  by  eating  and  relieved  by  vomiting,  sometimes  also  by  a 
change  of  position  which  allows  the  contents  of  the  stomach  to  gravi- 
tate away  from  the  ulcer.  Pressure  on  the  painful  spot  elicits  tenderness, 
but  it  is  often  found  to  afford  relief,  and  the  patient  bends  over  a  chair 


PEPTIC  ULCER  461 

or  lies  with  a  pillow  under  his  abdomen.  The  pain  commonly  radiates 
to  the  back,  sometimes  also  to  the  sides.  It  is  generally  felt  in  the  back 
at  a  point  a  little  to  the  left  of  the  tenth  dorsal  vertebra.  It  may  be 
continuous  for  weeks,  but  occasionally  ceases  for  a  variable  interval. 
Attacks  of  intense  gastralgia  sometimes  occur  independently  of  the  local 
condition.  This  is  generally  at  a  point  an  inch  or  two  below  the  ensi- 
form  cartilage  and  a  little  to  the  right  of  the  median  line. 

Vomiting  sometimes  occurs  without  much  nausea,  either  immediately 
after  meals  or  at  irregular  intervals  of  several  days.  The  vomitus  is 
usually]  highly  acid,  the  free  HCl  sometimes  reaching  0.5  per  cent.  The 
ferments  are  not  generally  altered  in  amount. 

Hemorrhage  occurs  in  nearly  or  quite  half  the  cases.  It  may  be 
slight,  but  it  is  generally  profuse  and  may  induce  syncope  or  convul- 
sions. Unaltered  blood,  bright  red  and  fluid,  is  brought  up  in  these 
cases.  Hemoptysis  is,  indeed,  one  of  the  most  characteristic  symptoms. 
A  free,  even  fatal,  hemorrhage  sometimes  results  from  a  small  superficial 
ulcer  or  a  scarcely  recognizable  erosion.  After  the  blood  has  remained 
in  the  stomach  for  a  short  time,  it  becomes  altered  and  mingled  with  the 
food.  Blood  from  either  a  gastric  or  a  duodenal  ulcer  can  generally  be 
found  in  the  stools  after  a  hematemesis,  and  sometimes  in  cases  which 
have  not  been  attended  with  hematemesis.  The  blood  appears  in  the 
stools  as  black,  tarlike  matter.  The  stools  should  always  be  examined 
in  a  case  of  suspected  ulcer. 

Perforation  occurs  in  about  6  per  cent  of  cases.  It  may  follow  undue 
pressure  or  the  ingestion  of  food.  It  is  more  common  in  women.  Its 
occurrence  is  announced  by  a  sudden  severe  pain  which  is  generally  con- 
fined to  the  epigastrium,  but  may  radiate  over  the  abdomen  or  be 
referred  to  another  region.  Collapse  quickly  follows;  the  abdomen  be- 
comes distended  and  tender,  the  pulse  small  and  rapid.  The  Hippocratic 
facies,  shallow  respiration,  and  other  manifestations  of  peritonitis  rapidly 
develop.  The  evidences  of  perforation  are  occasionally  the  first  indica- 
tion of  the  existence  of  the  ulcer. 

Complicaiions. — The  most  important  of  these  are  pylephlebitis,  with 
abscess  of  the  liver;  chronic  peritonitis;  and  suppurative  parotitis. 
Dilatation  of  the  stomach  follows  narrowing  of  the  pylorus  from  cicatri- 
zation, and  sclerosis  of  the  walls  is  not  uncommon. 

Diagnosis. — The  cardinal  symptoms  are  the  peculiar  localized  sensa- 
tion of  discomfort  or  of  pain  and  tenderness,  vomiting,  especially  hema- 
temesis accompanied  with  pronounced  anemia.  Ulcer  is  to  be  differenti- 
ated from  gastralgia,  hyperchlorhydria,  acute  gastritis,  and  cancer,  and 
the  hemorrhages  from  hematemesis  of  other  character. 

Gastralgia  is  a  neuralgic  pain  which  is  not  limited  to  a  definite  area, 
and  it  is,  as  a  rule,  neither  relieved  nor  intensified  by  the  taking  of  food. 
The  patient  does  not  become  anemic ;  digestion  may  be  normal  between 
the  attacks;  vomiting  seldom  occurs;  hematemesis  is  absent;  and  if  there 
is  tenderness,  it  is  difi'use.     Superacidity  may  be  present. 

In  hyperchlorhydria  the  pain  is  diffuse,  and  it  usually  occurs  two  or 
three  hours  after  the  ingestion  of  food. 

■Acute  gastritis  is  generally  accompanied  with  fever  and  evidences  of 
toxemia.  Blood  is  absent  from  the  vomited  matter,  or  present  in  only 
trifling  amount.    The  condition  does  not  usually  last  more  than  a  week. 


462  PRACTICE  OF  MEDICINE 

Carchioma  almost  always  occurs  in  individuals  past  40.  The  pain  is 
irregular,  sometimes  absent;  tenderness  may  not  develop  until  late. 
Vomiting  occurs  irregularly  or  it  is  absent ;  hematemesis  is  not  profuse, 
and  the  blood  usually  has  the  coffee-grounds  appearance.  A  tumor  can 
generally  be  felt,  and  the  patient  acquires  a  cachectic  appearance.  The 
free  HCl  is  usually  diminished  and  sometimes  absent. 

The  gastric  crises  of  locomotor  ataxia  sometimes  simulate  the  par- 
oxysms of  pain  from  ulcer  before  the  more  characteristic  symptoms  of 
the  disease  have  developed.  They  are  usually  associated,  however,  with 
the  lightning  pains,  ocular  symptoms,  and  absence  of  the  patellar  reflex. 

Chlorosis. — Hematemesis  sometimes  occurs  in  chlorotic  girls,  which 
cannot  always  be  attributed  to  an  ulcer,  on  account  of  the  rapidity  of 
the  recovery  which  follows.  It  is  believed  to  be  due  to  simple  vascular 
engorgement  of  the  gastric  mucous  membrane.  The  diagnosis  is  difficult, 
but  the  localized  pain  and  tenderness  of  ulcer  are  generally  absent,  and 
there  may  have  been  no  previous  indigestion. 

Gall-stone  colic  can  generally  be  recognized  by  the  location  and  char- 
acter of  the  pain,  its  sudden  onset  and  sudden  termination,  as  well  as  by 
the  enlargement  and  tenderness  of  the  liver,  sometimes  accompanied  with 
distention  of  the  gall-bladder  and  jaundice. 

The  hemateinesis  due  to  cirrhosis  of  the  liver  accompanies  the  charac- 
teristic symptoms  of  that  disease.  The  liver  is  small,  and  jaundice  and 
ascites  are  usually  present. 

The  differentiation  between  gastric  and  duodenal  ulcer  is  often  impos- 
sible. The  latter  location  of  the  ulcer  may  be  suspected,  however,  when 
a  sudden  intestinal  hemorrhage  (melena)  takes  place  in  a  previously 
healthy  person,  or  when  there  is  a  history  of  pain  in  the  right  hypochon- 
drium  two  or  three  hours  after  meals. 

Prognosis. — Recovery  usually  follows  appropriate  treatment,  but  re- 
currence is  common.  It  is  never  safe  to  give  a  favorable  prognosis, 
for  the  course  of  the  disease  is  exceedingly  uncertain.  The  danger  of 
perforation  is  always  to  be  regarded,  and  the  hemorrhages  sometimes 
prove  fatal.  A  chronic  ulcer  may  terminate  unfavorably  through  inani- 
tion and  exhaustion. 

Treatment — The  first  indication  is  to  give  the  stomach  complete  rest. 
This  may  be  accomplished  in  severe  cases  by  confining  the  patient  to 
bed  and  resorting  to  rectal  alimentation  for  at  least  the  first  week.  In 
ordinary  cases,  however,  it  is  sufficient  to  give  easily  digestible,  unirri- 
tating  food  in  small  quantities  at  regular  intervals.  It  is  generally  best 
to  give  only  milk  at  first;  4  ounces  every  two  hours.  It  may  be  plain 
or  peptonized,  and  buttermilk  often  agrees  better  than  sweet  milk.  Beef- 
juice  or  peptonized  beef,  and  egg  albumen,  may  be  allowed  after  a  few 
days,  and  the  diet  should  be  restricted  in  most  cases  to  such  articles  as 
these  during  the  first  month.  It  may  then  be  extended  so  as  to  include 
rare  beef,  the  white  meat  of  chicken,  poached  eggs,  toast,  and  well-cooked 
farinaceous  articles. 

Pain  is  rarely  so  intense  as  to  require  the  administration  of  morphin. 
Relief  can  generally  be  obtained  from  alkalis,  as  sodium  bicarbonate,  the 
compound  spirit  of  sulphuric  ether,  camphor-water,  or  a  few  drops  of 
chloroform. 

When  vomiting  is  persistent,  it  may  be  necessary  to  adopt  rectal  ali- 


CANCER  OF  THE  STOMACH  463 

mentation.  Mustard  may  be  applied  to  the  epigastrium,  or  a  few  quick 
strokes  may  be  made  with  the  cautery.  The  vomiting  is  sometimes 
checked  by  bismuth,  with  or  without  opium,  by  dilute  hydrocyanic  acid, 
chloroform,  or  by  sipping  a  carbonated  water  or  champagne.  Lavage 
with  a  warm  alkaline  solution  has  been  recommended,  but  it  should  be 
performed  with  the  utmost  care.  The  action  of  the  bowels  must  gener- 
ally be  regulated  by  either  a  saline  laxative  or  enemata.  Thirst  is  best 
relieved  by  enemata  of  salt  water.  The  powder  of  Stockton  and  Jones 
often  proves  an  excellent  remedy  for  the  pain,  vomiting,  and  constipation. 
Each  powder  contains  :  Of  cerium  oxalate,  gr.  ij  (0.13);  light  magnesium 
carbonate,  gr.  x  (0.65);  and  bismuth  subcarbonate,  gr.  xx  (1.30).  It 
should  be  administered  from  three  to  six  times  a  day.  A  grain  or  two 
of  reduced  iron  should  be  added  to  each  powder,  for  the  anemia. 

For  the  healing  of  the  ulcer,  large  doses  of  bismuth  subcarbonate,, 
gr.  xxx  to  Ix  (2.0 — 4.0)  three  times  a  day,  are  of  unquestionable  benefit. 
The  nitrate  of  silver  in  doses  of  gr.  ]/l  (0.016),  combined  with  opium, 
was  highly  recommended  by  Pepper. 

When  hemorrhage  occurs,  the  patient  should  be  immediately  placed 
under  the  influence  of  morphin,  given  hypodermically  at  such  intervals  as 
will  insure  complete  rest  for  several  days.  Ergotin,  gr.  ij  (0.13),  may 
also  be  administered  hypodermically.  Astringent  remedies  per  os  are 
useless.  In  extreme  cases  the  subcutaneous  injection  of  saline  solution 
should  be  resorted  to.  During  convalescence  iron  should  be  administered 
freely  in  a  nonirritating  form.  The  reduced  iron  is  probably  best. 
Surgery  has  accomplished  excellent  results  in  a  few  instances  after  per- 
foration or  persistent  hemorrhage.  The  source  of  the  bleeding  cannot 
always  be  discovered,  but  ligature  of  the  artery  in  the  stomach-wall 
which  supplies  the  region  has  resulted  in  arrest  of  the  hemorrhage  and 
healing  of  the  ulcer. 

CANCER  OF  THE  STOMACH. 

Etiology. — Sex  and  Age. — The  sexes  are  about  equally  affected.  More 
than  half  the  cases  occur  between  the  ages  of  40  and  60;  the  disease  is 
rare  under  30,  but  cases  have  been  observed  in  children,  and  a  few  con- 
genital cases  have  been  reported.  Next  to  the  uterus,  the  stomach  is  the 
most  frequent  location  of  cancer. 

Race. — The  disease  is  much  more  frequent  in  the  white  race  than 
among  negroes. 

Heredity  is  regarded  as  a  strong  predisposing  factor,  but  in  many 
cases  no  such  influence  can  be  traced. 

Previous  Disease  and  Habits. — That  previous  irritation  of  the  stomach 
is  influential  is  inferred  from  the  frequent  location  of  the  growth  in  the 
pyloric  region  as  well  as  from  the  frequent  history  of  long-standing 
catarrh  before  its  onset.  In  about  6  per  cent  of  cases  there  is  a  more  or 
less  definite  history  of  ulcer,  or  of  injury  to  the  region  of  the  stomach. 
A  considerable  proportion  of  cancer  patients  have  been  addicted  to  free 
indulgence  in  alcohol.  But  in  general  no  great  importance  can  be  at- 
tached to  previous  disease,  habits,  occupation,  or  station  in  life. 

Bacteria. — Cancer  is  regarded  by  many  authorities  as  a  specific  infec- 
tion, but  the  microbe  has  not  been  identified.    It  is  possible  that  some 


464  PRACTICE  OF  MEDICINE 

one  of  the  micro-organisms  recently  demonstrated  in  the  growth,  and 
cultivated  with  more  or  less  success,  will  prove  to  be  the  cause  of  the  dis- 
ease. Cancer  of  the  stomach  is  usually  primary,  but  it  is  sometimes 
secondary  to  cancer  of  one  of  the  adjacent  organs. 

Morbid  Anatomy. — The  different  types  of  cancer  are  found  in  the  fol- 
lowing order  of  frequency  :  (i)  Cylinder-celled  epithelioma,  (2)  encepha- 
loid,  (3)  scirrhous,  (4)  colloid.  The  epithelioma  is  much  the  most 
common.  The  soft  encephaloid  or  medullary  and  the  colloid  are  the 
most  rapid  in  growth  and  invasion  of  tissues,  and  the  hard  scirrhous  is 
least  so.  The  epithelioma  and  scirrhus  are  usually  found  as  compara- 
tively small  masses,  while  the  encephaloid  and  colloid  frequently  invade 
almost  the  entire  wall  of  the  stomach.  The  growth  most  commonly 
originates  near  the  pylorus,  next  in  the  lesser  curvature,  then  at  the 
cardia,  the  posterior  wall,  the  greater  curvature,  and  finally  in  the  fun- 
dus.    Multiple  tumors  are  occasionally  encountered. 

The  stomach  is  dilated  as  a  result  of  cancer  at  the  pylorus,  and  much 
contracted  when  the  growth  is  located  at  the  cardiac  orifice.  The  esoph- 
agus is  much  dilated  above  a  tumor  at  the  cardia.  In  some  cases  of 
pyloric  scirrhus,  however,  the  stomach  is  contracted,  although  marked 
stenosis  may  have  been  produced.  The  stomach  may  be  displaced  down- 
ward by  its  weight,  and  it  may  drag  with  it  the  surrounding  viscera.  In 
some  cases  the  tumor  is  remarkably  movable,  while  in  others  adhesions 
are  formed  between  the  stomach  and  colon,  liver,  or  anterior  abdominal 
wall.  Metastatic  growths  are  often  found  in  the  lymph-glands,  liver, 
gall-bladder,  peritoneum,  omentum,  intestine,  pancreas,  spleen,  pleura,  and 
lungs,  or  elsewhere.  Small  subcutaneous  cancers  are  sometimes  found  in 
the  epigastric  and  hypogastric  regions. 

Symptoms. — There  is  great  diversity  in  the  symptoms  of  different 
cases.  There  may  be  no  manifestations  by  which  the  disease  can  be 
recognized  until  a  comparatively  late  period.  The  history  that  is  gener- 
ally obtained  is  that  of  indigestion  during  several  months,  increasing  in 
severity,  and  attended  with  anemia  and  emaciation.  The  disease  is 
sometimes  discovered  post  mortem  in  those  dying  from  other  causes. 
In  another  class  of  cases  the  s)anptoms  appear  comparatively  early  and 
are  characteristic.  The  disturbances  caused  by  the  metastatic  growths, 
especially  in  the  liver,  are  occasionally  more  prominent  than  those  of  the 
primary  disease. 

The  early  symptoms  in  an  ordinary  case  are  loss  of  appetite,  impaired 
digestion,  pain,  nausea,  and  vomiting.  Later  there  are  loss  of  weight 
and  strength,  anemia,  emaciation,  cachexia,  and  finally  prostration,  and 
death  from  toxemia  or  exhaustion.  The  early  symptoms  are  not  typical ; 
they  indicate  only  a  disturbance  of  the  function  of  the  stomach.  The 
loss  of  appetite  is  an  early  symptom,  and  it  is  one  of  the  most  constant. 
The  tongue  becomes  heavily  coated  and  dry.  Nausea  and  distress  soon 
develop  after  meals;  then  the  feeling  of  oppression  in  the  stomach  be- 
comes more  constant,  and  it  is  aggravated  into  a  distinct  pain  by  the 
ingestion  of  food.  Eructations  become  a  prominent  feature,  and  then 
occasional  vomiting, 

Votniting. — In  some  cases  neither  nausea  nor  vomiting  is  present 
throughout  the  disease,  but  in  others  they  are  extremely  troublesome 
symptoms,  especially  in  the  last  stages.    Vomiting  is  more  frequently 


CANCER  OF  THE  STOMACH  465 

present  when  the  cancer  is  situated  at  the  pylorus,  and  more  frequently 
absent  when  it  is  at  a  distance  from  this  region.  It  is  observed,  how- 
ever, early  or  late,  in  about  four-fifths  of  all  cases.  It  often  bears  no 
relation  to  the  taking  of  food.  The  vomitus  may  consist  only  of  food 
and  mucus,  or  it  may  contain  adventitious  matter,  particularly  blood. 
It  has  a  sour  odor  and  in  some  cases  becomes  distinctly  fetid  or  fecu- 
lent, especially  as  a  result  of  the  separation  of  gangrenous  sloughs  from 
the  tumor.  The  food  may  show  but  little  digestion,  after  having  re- 
mained in  the  stomach  many  hours. 

Hemorrhage. — Free  hematemesis  is  rare.  The  blood  is  sometimes  so 
small  in  quantity  that  it  can  be  discovered  only  by  microscopic  or  chem- 
ical examination.  Altered  corpuscles  can  often  be  recognized;  hemin 
crystals  may  be  obtained,  or  the  guaiacum  test  may  be  applied.  In 
other  cases  the  blood  appears  as  coffee-ground  matter,  which  is  regarded 
as  highly  pathognomonic  of  cancer.  Large  ulcerating  cancers  are  most 
liable  to  be  attended  with  free  hemorrhage ;  scirrhus  often  runs  its  course 
without  it. 

Pain  is  a  prominent  symptom  in  about  three-fourths  of  the  cases  and 
often  occurs  early.  It  is  usually  confined  to  the  epigastrium,  but  may 
be  referred  to  the  shoulders,  sides,  or  back.  It  is  generally  of  a  burning, 
gnawing,  or  dragging  character;  distinct  cardialgia  rarely  occurs.  It  is 
generally  constant,  but  increased  by  ingestion  of  food.  Tenderness  is 
usually  elicited  by  pressure  over  the  region  aff'ected,  sometimes  also  over 
the  back  between  the  fifth  and  twelfth  dorsal  vertebrae. 

Anernia  and  cachexia  are  often  early  symptoms  and  almost  invariably 
present.  The  number  of  red  corpuscles  often  sinks  below  3,000,000, 
occasionally  below  2,000,000,  and  the  hemoglobin  may  fall  below  50 
per  cent.  The  anemia  is  one  of  the  chief  elements  in  the  production  of 
cachexia,  but,  in  addition,  the  skin  acquires  a  pale  yellow  tint,  often 
associated  with  brownish  discoloration  of  the  face,  neck,  and  backs  of 
the  hands  or  other  regions.  The  skin  appears  firm  and  inelastic,  some- 
times slightly  edematous.  When  the  anemia  is  extreme,  there  is  often 
edema  of  the  lower  extremities  and  sometimes  a  more  general  dropsy. 

Emaciatio7i  often  begins  early,  but  in  a  large  proportion  of  cases  there 
is  little  loss  of  weight  until  a  late  period  of  the  disease.  The  degree  of 
emaciation  is  often  remarkable,  the  body  being  literally  reduced  to  "  skin 
and  bones."  The  decline  of  strength  usually  keeps  pace  with  the  loss  of 
flesh,  but  a  remarkable  degree  of  vigor  is  sometimes  retained  to  the  end. 

Fever  is  not  a  prominent  symptom,  but  there  is  usually  some  eleva- 
tion of  temperature  during  the  course  of  the  disease.  It  may  not  occur 
until  late,  and  may  never  exceed  101°  F.  (38.5°  C),  but  toward  the  end 
it  often  rises  to  103°  F.  (39.5°  C.)  or  higher.  When  suppuration  occurs 
at  any  time,  in  the  growth  or  near  it,  fever  is  commonly  produced.  The 
pulse  becomes  weak.  Thrombosis  of  one  of  the  femoral  veins,  rarely  of 
other  vessels,  has  been  encountered. 

The  iirine  often  remains  unchanged.  Indican  may  be  present,  however, 
and  sometimes  a  small  quantity  of  albumin.  Aceton,  pepton,  and  glu- 
cose are  occasionally  found  in  it.  Constipation  prevails  in  most  cases, 
rarely  diarrhea.     Blood  may  be  occasionally  found  in  the  stools. 

The  tumor  can  usually  be  recognized  at  some  time  during  the  course 
of  the  disease  when  it  is  situated  at  the  pylorus;  less  frequently  when  at 

30 


466  PRACTICE  OF  MEDICINE 

the  cardia  or  lesser  curvature.  The  diffuse  carcinoma  seldom  produces  a 
prominence  that  can  be  felt.  It  is  usually  recognized  by  palpating 
deeply  into  the  epigastrium  just  to  the  right  of  the  median  line.  It  is  at 
first  slightly  movable,  sometimes  freely  so,  but  later  it  ma)'-  become 
adherent.  It  may  be  firm  and  smooth  or  nodular.  As  it  enlarges  it 
usually  transmits  the  pulsations  of  the  aorta  wdth  distinctness.  Som.e- 
times  it  drags  down  the  stomach  and  other  viscera  to  a  lower  position 
in  the  abdomen.  In  most  cases,  a  pyloric  cancer  causes  obstruction, 
consequent  increase  of  the  peristaltic  movement,  and,  later,  dilatation  of 
the  stomach.  Occasionally,  however,  the  pyloric  orifice  is  held  open, 
permitting  a  regurgitation  of  bile  into  the  stomach. 

The  motor  efficiency  of  the  organ  is  impaired  in  nearly  all  cases,  ex- 
cept those  involving  the  cardia  or  in  the  presence  of  small  tumors  of  the 
fundus.  It  is  most  reduced  when  a  large  portion  of  the  stomach-wall 
has  been  invaded  by  the  growth.  WTien  the  tumor  is  located  at  the  car- 
dia, the  stomach  generally  becomes  contracted,  and  in  other  respects  the 
symptoms  are  the  same  as  those  of  cancer  of  the  esophagus. 

Physical  Examinaiion. — Inspection. — From  this  we  learn  the  general 
condition  of  the  patient  as  to  nutrition ;  his  color,  whether  anemic  or 
cachectic,  and  the  presence  of  abnormal  pigmentation.  The  abdomen 
usually  appears  prominent,  and  the  lower  intercostal  spaces  may  be 
widened.  Small  subcutaneous  nodules  in  the  epigastric  or  umbilical 
region  are  often  of  diagnostic  value,  \^^len  the  tumor  is  large  it  may 
protrude  slightly,  and  the  transmitted  aortic  pulsation  may  become 
visible.  Exaggerated  peristaltic  movements  are  often  seen  comparatively 
early.  They  are  more  readily  recognized  after  the  stomach  has  been 
inflated  with  air,  but  this  method  should  not  be  practiced  in  a  case  of 
extensive  involvement  or  after  hemorrhage  has  occurred. 

Palpation  affords  more  positive  means  of  recognizing  the  tumor.  In 
some  cases  it  can  be  recognized  by  examining  the  patient  in  a  recumbent 
posture ;  in  other  cases  by  placing  him  in  the  knee-elbow  position.  Some- 
times the  tumor  can  be  felt  only  during  inspiration.  The  mobility  of  the 
growth  is  often  of  diagnostic  value ;  not  only  the  extent  to  which  it  can 
be  displaced  with  the  hand,  but  also  the  extent  to  which  it  moves  during 
respiration  and  with  peristalsis  or  with  inflation.  Tumors  of  the  pylorus 
are  occasionally  extremely  movable,  so  that  they  can  be  displaced  into 
either  hypochondriac  region  or  drawn  down  to  the  umbilicus.  Through 
palpation,  also,  the  escape  of  gas  through  the  narrowed  pylorus  can  be 
discerned,  as  in  other  forms  of  stenosis.  Percussion  is  seldom  of  much 
value,  and  auscultation  reveals  nothing  characteristic. 

Examination  of  the  Stomach-Contents.  — (Y ox  methods  see  p.  719.) 
HCl  is  not  invariably  absent,  but  its  persistent  absence  is  regarded  as 
highly  pathognomonic  of  cancer,  especially  that  of  the  pyloric  region.  It 
serves  also  to  distinguish  cancer  of  the  stomach  from  that  of  adjacent 
organs.  Lactic  acid  is  often,  but  not  invariably,  found.  Its  constant 
presence  is  regarded  as  of  greater  diagnostic  importance  than  the  absence 
of  HCl.  The  rennet,  or  milk-curdling  ferment,  is  generally  reduced  in 
quantity.  On  microscopic  examination,  various  micro-organisms  are 
ordinarily  found,  among  them  the  Boas-Oppler  bacillus,  a  long,  non- 
motile  rod,  which  is  supposed  to  be  operative  in  the  production  of  lactic 
acid.     Yeast  fungi  are  usually  found,  and  sarcinai  may  be  present. 


CANCER  OF  THE  STOMACH  467 

The  course  of  the  disease  seldom  exceeds  a  year  or  eighteen  months, 
and  cases  are  occasionally  reported  which  apparently  run  their  course  in 
three  or  four  months. 

Comp/icaf/ons.— Such  more  or  less  direct  results  as  dilatation  or  per- 
foration, and  such  pressure  symptoms  as  occlusion  of  the  bile-ducts  or 
blood-vessels,  and  the  development  of  metastatic  growths  are  often  re- 
ferred to  as  complications.  The  metastases  are  most  commonly  encoun- 
tered in  the  liver,  lymph-glands,  omentum,  mesentery,  pancreas,  occasion- 
ally in  the  spleen,  lungs,  pleura,  axillary  glands,  the  pelvic  organs,  or 
other  parts. 

Diagnosis— The  early  recognition  of  cancer  of  the  stomach  is  often 
extremely  difficult,  especially  its  differentiation  from  chronic  gastritis  and 
ulcer.  It  is  to  be  suspected  especially  when  it  develops  pronounced 
symptoms  of  gastritis  in  a  person  who  has  always  been  healthy,  and 
more  particularly  when  anemia  and  cachexia  become  apparent  and  when, 
in  an  elderly  person,  the  indigestion  is  accompanied  with  pain.  The 
methods  of  examination  already  referred  to  may  render  the  recognition 
of  the  disease  possible.  When  a  tumor  is  discovered,  it  strongly  supports 
the  diagnosis.  The  diseases  from  which  cancer  is  to  be  particularly 
differentiated  are  chronic  gastritis,  ulcer,  and  the  severe  primary  anemias. 

In  chronic  gastritis  there  is  usually  a  history  of  long-continued  indiges- 
tion, without  tumor  or  cachexia,  and  the  blood-changes  are  less  pro- 
nounced.    Lactic  acid  is  not  generally  found  after  a  test-meal. 

Ulcer  is  to  be  distinguished  especially  by  the  presence  of  hyperchlor- 
hydria,  the  gastralgic  attacks,  and  the  profuse  hemorrhages.  It  usually 
occurs  in  younger  subjects. 

Anemia. — Grave  anemia  is  often  suggested  by  the  appearance,  espe- 
cially when  the  digestive  disturbances  are  of  only  moderate  severity  and 
when  tumor  is  absent.  In  countries  where  profound  anemia  is  a  common 
result  of  animal  parasites,  the  differentiation  may  be  especially  difficult, 
until  examination  of  the  feces  is  made.  In  pernicious  anemia  the  blood- 
count  shows  a  more  profound  diminution  of  the  red  corpuscles  than  is 
observed  in  cancer.  In  cases  of  doubt,  an  exploratory  incision  is  to  be 
recommended.  In  many  cases,  without  such  examination  the  case  must 
remain  in  doubt  until  the  development  of  characteristic  symptoms,  possi- 
bly several  months  after  the  first  examination. 

Prognosis. — The  disease  is  invariably  fatal.  The  only  exceptions  are 
the  few  cases  in  which  early  removal  of  the  tumor  has  more  or  less 
permanently  arrested  the  disease. 

Treatment. — The  most  important  question  is,  Can  anything  be  done 
by  surgical  measures?  If  not,  the  treatment  is  wholly  palhative.  The 
management  of  the  digestive  disturbances  is  that  of  chronic  gastritis, 
and  perhaps  that  of  dilatation.  When  HCl  is  absent  or  greatly  deficient, 
it  should  be  supplied  by  the  administration  of  the  dilute  acid.  When 
stenosis  occurs,  the  patient  may  be  nourished  by  the  rectum,  but  usually 
only  for  a  very  short  time.  Previous  to  this  the  most  easily  digestible 
and  most  nourishing  food  must  be  given,  as  finel}^  chopped  meats,  soft 
vegetables,  salads,  eggs,  rice,  custards,  and  the  like.  When  the  tumor  is 
at  the  cardia,  the  diet  must  be  entirely  liquid  in  most  cases.  Much 
benefit  and  prolongation  of  life  have  followed  in  some  instances  the  in- 
troduction of  the  gastric  canula.     Milk  is  often  the  best  food.    When 


468  PRACTICE  OF  MEDICINE 

vomiting  interferes  with  the  nutrition,  the  food  will  sometimes  be  re- 
tained if  introduced  through  the  stomach-tube.  Predigested  milk  or  beef, 
egg-nog,  beef-juice,  broths,  and  gruels  can  usually  be  taken.  When  the 
tumor  is  located  at  the  pylorus,  lavage  often  gives  marked  relief  from 
the  suffering  and  assists  nutrition.  It  should  usually  be  practiced  in  the 
morning,  and  always  with  great  care.  The  most  successful  surgical 
measure  has  been  gastroenterostomy.  The  pylorus  and  in  some  in- 
stances the  entire  stomach  have  been  removed,  but  in  most  instances 
extreme  measures  for  prolonging  life  result  in  little  more  than  prolonga- 
tion and  aggravation  of  suffering.  Marked  temporary  improvement 
has  repeatedly  followed  an  exploratory  incision  or  any  other  measure 
which  awakens  a  strong,  though  false,  hope  of  improvement. 

OTHER  TUMORS. 

The  nonmalignant  fibromata  and  papillomata  and  the  malignant 
lymphosarcomata  have  been  found  in  the  stomach.  They  are  seldom 
diagnosticated  during  life.  Foreign  bodies  may  also  assume  the  char- 
acter of  tumors.  A  not  infrequent  form  is  the  hair  tumor,  which  re- 
sults from  the  swallowing  of  hair,  especially  by  hysterical  women.  These 
sometimes  acquire  enormous  size  and  cause  more  or  less  complete  ste- 
nosis of  the  pylorus.  Large  masses  of  fruit-seeds  and  rinds  and  numer- 
ous other  substances  have  been  found  and  successfully  removed  through 
surgical  operations. 

HYPERTROPHIC  STENOSIS. 

This  rather  rare  condition  is  due  to  a  hypertrophy  of  the  muscular 
and  submucous  coats  of  the  stomach,  which  may  form  a  mass  recogniza- 
ble on  palpation.  It  is  sometimes  congenital,  but  is  generally  recog- 
nized later  in  life,  at  any  time  after  the  twelfth  year.  The  causes  which 
produce  it  in  adults  are  not  known.  The  principal  symptoms  are  those 
of  dilatation.  The  diagnosis  is  seldom  made  during  life.  The  treatment 
is  purely  surgical,  and  the  usual  operation  is  that  of  gastroenterostomy. 

HEMORRHAGE  OF  THE  STOMACH. 

GASTRORRHAGIA,   HEMATEMESIS. 

Bleeding  of  the  stomach  (gastrorrhagia)  and  vomiting  of  blood 
(hematemesis)  are  symptoms  of  a  variety  of  conditions. 

Etiology. — Hematemesis  sometimes  results  from  the  entrance  of  blood 
into  the  stomach  from  other  sources,  as  when  swallowed  in  hemorrhage 
of  the  upper  respiratory  tract,  pharynx,  or  esophagus,  or  when,  it  flows 
in  through  the  cardiac  orifice  after  rupture  of  a  varicosed  vein  in  the 
lower  extremity  of  the  esophagus  in  cirrhosis  of  the  liver,  or  very  rarely 
from  the  rupture  of  an  aneurism  into  the  stomach  or  esophagus.  It 
occasionally  results  from  the  passage  of  blood  through  the  pylorus  from 
the  intestine  in  cases  of  duodenal  ulcer.  The  causes  of  gastrorrhagia 
may  be  either  local  or  general. 

I.   The  most  frequent  local  causes  are:  (<7)  Peptic  ulcer  and  cancer; 


HEMORRHAGE  OF  THE  STOMACH  469 

(^)  passive  congestion  due  to  obstruction  of  the  portal  circulation,  as 
in  hepatic  cirrhosis,  pressure  of  a  tumor,  thrombosis  of  the  portal  vein, 
chronic  valvular  disease  of  the  heart,  and  fibrosis  or  emphysema  of  the 
lungs;  (<:)  enlargement  of  the  spleen.  (^)  Traumatic  hemorrhage  also 
occurs  as  a  result  of  blows  and  wounds  or  the  introduction  of  the  stom- 
ach-tube or  sounds,  and  it  may  follow  the  action  of  corrosive  poisons, 
phosphorus,  or  alcohol,  or  the  injury  occasioned  by  a  foreign  body. 
(^)  A  toxic  cause  is  sometimes  recognized,  when  it  occurs  in  connection 
with  such  acute  infections  as  measles,  smallpox,  yellow  fever,  pernicious 
malaria,  and  dengue,  or  in  acute  yellow  atrophy  of  the  liver. 

2.  The  general  conditions  causing  it  are  (a)  chlorosis,  pernicious 
anemia,  leukemia,  purpura,  scurvy,  and  hemophilia.  (^)  Vicarious 
menstruation  from  the  stomach  has  been  observed.  (^)  Hemorrhage 
of  the  stomach  alone  or  in  connection  with  the  bleeding  of  other  mucous 
membranes  occasionally  occurs  in  the  new-born  infant.  (^)  Hemateme- 
sis  is  sometimes  feigned  by  hysterical  women  who  vomit  blood  or  col- 
ored fluids  that  have  been  previously  swallowed. 

Morbid  /Inatomy.— In  the  absence  of  such  definite  lesions  as  ulcer, 
cancer,  corrosion,  or  other  injury,  the  source  of  the  blood  may  be  de- 
termined with  difficulty,  if  at  all,  since  it  often  comes  from  numerous 
small  erosions  which  are  not  recognizable  after  death,  or  from  the  rup- 
ture of  a  miliary  aneurism  or  a  small  vein  in  the  submucosa  which  oc- 
casions so  slight  lesions  of  the  surface  as  not  to  be  discovered  on  careful 
examination.  When  death  has  resulted  from  the  hemorrhage,  the  mucous 
membrane  participates  in  the  general  anemic  condition  and  appears  ex- 
tremely pale. 

Symptoms. — The  blood  may  be  retained  in  the  stomach,  even  in  cases 
of  fatal  hemorrhage.  The  quantity  vomited  in  other  cases  may  vary 
from  two  or  three  ounces  to  as  many  pints  or  even  more.  Fatal  hem- 
orrhage most  frequently  results  from  ulcer  or  the  rupture  of  varicose 
esophageal  veins  in  cirrhosis ;  death  may  ensue  from  a  single  hemorrhage, 
but  more  commonly  as  a  result  of  repeated  hemorrhages  during  several 
days.  Free  hematemesis  often  brings  up  bright  red  arterial  blood,  but 
if  the  blood  has  been  retained  in  the  stomach  for  a  short  time  it 
assumes  the  character  of  coffee-grounds  or  chocolate-colored  masses, 
which  become  bright  red  on  the  surface  after  exposure  to  the  air.  The 
blood  may  be  mixed  with  food,  mucus,  or  pus.  Melena  is  also  a  com- 
mon symptom.  Such  other  symptoms  of  hemorrhage  are  observed  as 
pallor,  restlessness,  rapid  feeble  pulse,  accelerated  respiration,  cold  per- 
spiration, subnormal  temperature,  syncope,  or  convulsions. 

Diagnosis.— When  a  large  quantity  of  blood  is  retained  in  the  stom- 
ach, the  fact  that  a  hemorrhage  has  occurred  can  generally  be  recog- 
nized by  the  pallor,  cardiac  weakness,  rapid  respiration,  and  other  in- 
dications already  referred  to.  The  percussion  note  over  the  stomach 
is  fiat.  The  statement  of  the  patient  that  blood  has  been  vomited  can- 
not always  be  accepted,  for  deception  is  sometimes  practiced  by  the  h3^s- 
terical,  and  errors  have  occurred  from  the  staining  of  the  stomach  con- 
tents with  fruit-juices  or  red  wine  or  from  the  black  discoloration  caused 
by  bismuth  or  iron.  Such  stains  can  generally  be  recognized  by  mere 
ocular  inspection,  but  microscopic  or  chemical  examination  is  sometimes 
necessary.    The  most  important  distinction  is  usually  to  be  made  be- 


47 o  PRACTICE  OF  MEDICINE 

tween  hematemesis  and  hemoptysis.  In  hematemesis  there  is  usually 
a  history  of  gastric,  hepatic,  or  splenic  disorder,  an  acute  infection,  toxic 
or  mechanical  injury,  and  the  blood  is  brought  up  by  vomiting  in  a 
more  or  less  changed  condition  and  often  mixed  with  food,  mucus,  or  gas- 
tric juice,  which  gives  an  acid  reaction.  In  hemoptysis  there  is  the  his- 
tory of  cough  or  other  evidence  of  pulmonary  or  cardiac  disease ;  the 
blood  is  raised  by  coughing  and  it  is  bright  red  and  frothy,  of  alkaline 
reaction,  rarely  clotted,  but  sometimes  mixed  with  mucus  or  pus.  Vom- 
iting may  accompany  the  hemorrhage,  and  hence  the  presence  of  stom- 
ach-contents cannot  be  regarded  as  evidence  against  hemoptysis.  Aus- 
cultation generally  reveals  numerous  moist  rales  or  coarse  bubbling  in 
one  of  the  lungs.  Following  hematemesis,  tarry  stools  commonly  occur, 
and  after  hemoptysis  the  sputum  continues  to  be  blood-stained  for 
several  days. 

Prognosis. — The  hematemesis  of  ulcer  or  cancer  is  not  commonly  fatal; 
that  from  cirrhosis  of  the  liver,  splenic  enlargement,  the  rupture  of  an 
aneurism,  or  penetrating  wounds  is  generally  so. 

For  the  treatment  of  hematemesis  see  that  of  gastric  ulcer. 

NEUROSES  OF  THE  STOMACH. 

NERVOUS  DYSPEPSIA. 

Definiiion. — This  term  has  been  applied  to  a  group  of  functional  dis- 
orders which  occur  without  discoverable  anatomical  lesions.  They  are 
in  nature  either  secretory,  motor,  or  sensory. 

Etiology. — Underlying  all  cases  of  true  neurosis  there  is  a  disordered 
state  of  the  nervous  system.  This  may  be  inherited  or  acquired.  It 
often  happens,  however,  that  the  gastric  symptoms  are  so  prominent  as 
for  a  time  to  overshadow  the  general  nervous  condition.  The  inherited 
form  often  shows  itself  in  different  members  of  the  same  family.  The  ac- 
quired neuroses  result  from  nervous  excitement,  worry,  overwork,  espe- 
cially in  a  confining  occupation,  and  are  favored  by  neglect  of  hygiene, 
irregular  or  hurried  meals,  and  loss  of  rest.  Eyestrain,  especially  that 
due  to  astigmatism  and  errors  of  refraction,  has  been  adduced  as  a  cause. 
The  neuroses  sometimes  develop  in  the  course  of  the  acute  infections 
or  as  a  sequel  to  them.  The  gastric  crises  of  locomotor  ataxia  are 
regarded  as  a  neurosis.  More  than  one  form  of  neurosis  is  often  pres- 
ent in  the  same  case,  and  the  severity  of  the  condition  varies  within 
broad  limits. 

I.   NEUROSES  OF  SECRETION. 

(flt)  Supersecretion  or  Superacidity. — This  is  a  rather  rare  condition, 
but  is  sometimes  seen  in  connection  with  neurasthenia,  locomotor  ataxia, 
and  other  nervous  affections.  The  entire  quantity  of  the  gastric  juice  is 
increased,  its  acidity  remaining  normal  or  undergoing  increase.  In  most 
cases  the  condition  is  constant,  but  it  may  be  periodic,  lasting  for  sev- 
eral days  at  a  time. 

Symptoms.— The  periodic  attack  usually  sets  in  with  a  gnawing  sen- 
sation in  the  stomach  and  headache.  Vomiting  soon  follows,  with  the 
ejection  of  a  large  quantity  of  watery  fluid,  which  is  so  highly  acid  in 
most  instances  that  it  irritates  the  throat  and  leaves  it  raw  and  sore. 


NEUROSES  OF  THE  STOMACH 


471 


The  secretion  of  the  fluid  is  remarkably  rapid.  One  of  the  principal  re- 
sults of  constant  superacidity  is  spasm  of  the  pylorus  from  the  irrita- 
tion produced  by  the  highly  acid  juices  constantly  bathing  it.  Dilatation 
commonly  follows.  There  is  a  sense  of  weight  and  oppression  in  the 
epigastrium,  and  the  digestion  is  impaired.  Vomiting  at  night  or  early 
in  the  morning  is  a  characteristic  feature  in  many  cases. 

(/^)  Hyperchlorhydria  (Superacidity,  Acid  Dyspepsia). — In  this  con- 
dition the  percentage  of  HCl  is  increased  during  digestion.  The  condi- 
tion is  generally  seen  in  young  neurotic  girls  and  often  in  connection 
with  chlorosis. 

Sympioms. — Pain  of  a  burning  character,  or  a  sensation  of  weight 
and  pressure,  is  the  most  common  and  most  characteristic  symptom. 
It  occurs,  as  a  rule,  from  one  to  three  hours  after  the  ingestion  of  food. 
Acid  eructations  generally  occur,  and  sometimes  vomiting.  There  is 
also  tenderness  in  the  pit  of  the  stomach,  as  in  ulcer,  a  disease  in 
which  superacidity  is  commonly  present,  but  not  as  a  neurosis.  The 
patient  is  often  aroused  from  sleep  by  the  distress  or  by  the  sensation 
of  hunger,  which  is  almost  constantly  present.  Temporary  relief  is  gen- 
erally afforded  by  vomiting  or  the  ingestion  of  food,  particularly  by 
animal  food. 

Treaimeni. — In  superacidity  or  hyperchlorhydria  the  patient  should 
be  placed  on  an  exclusively  milk  diet  for  the  first  few  days.  Then  beef, 
fish,  eggs,  and  dry  toast  may  be  added  to  the  list.  Alcoholic  drinks 
should  be  excluded,  and  the  use  of  tobacco  would  better  be  abandoned. 
Relief  from  the  pain  and  eructations  is  afforded  by  sodium  bicarbonate, 
magnesium  carbonate,  and  other  alkalis.  They  should  not  be  admin- 
istered, however,  until  the  distress  is  felt.  The  compound  spirit  of  sul- 
phuric ether  and  chloroform-water  give  temporary  relief.  Atropin  has 
been  employed  to  reduce  the  quantity  of  secretion. 

(r)  Hypochlorhydria  (Subacidity).— In  this  condition  the  quantity 
of  HCl  is  reduced  below  0.14  per  cent.  It  is  generally  believed  to  re- 
sult from  deficient  innervation. 

Sympioms. — The  symptoms  are  those  of  chronic  gastritis,  without, 
however,  an  arrest  of  the  secretion  of  pepsin  and  rennin  or  the  excessive 
secretion  of  mucus. 

Treatment. — The  normal  secretion  can  generally  be  restored  by  the 
administration  of  bitter  tonics,  as  the  compound  tincture  of  gentian, 
with  the  tinctures  of  nux  vomica  and  capsicum,  immediately  after  meals. 
Dilute  hydrochloric  acid  is  also  beneficial.  Some  cases  recover  more 
promptly  on  the  administration  of  an  alkaline  solution,  as  sodium  bi- 
carbonate, gr.  XX  (1.30)  in  a  half-pint  of  hot  water  twenty  minutes 
before  each  meal,  and  the  dilute  hydrochloric  acid,  gtt.  xx  in  water 
immediately  after  the  meal.  The  diet  should  consist  chiefly  of  farinaceous 
food,  as  well-cooked  cereals,  and  very  little  meat. 

((/)  Achylia  Gastrica  (Nervous  Anacidity). — A  condition  in  which  the 
gastric  secretion  is  permanently  absent.  As  a  true  neurosis  it  is  usually 
due  to  some  reflex  irritation,  as  that  of  eyestrain  in  asymmetrical  as- 
tigmatism. The  term  is  commonly  applied,  however,  to  conditions  in 
which  the  gastric  juice  fails  of  secretion  on  account  of  atrophy  of  the 
peptic  glands,  as  in  some  cases  of  chronic  gastritis,  a  condition  in  which 
it  is  not  truly  a  neurosis,   but  depends  upon  anatomical  lesions.    The 


472.  PR.\CTICE  OF  MEDICINE 

absence  of  HCl  in  cancer  and  sometimes  in  tabes  is  regarded  as  a 
neurosis. 

Symptoms. — In  many  cases  there  are  no  subjective  symptoms,  and  the 
condition  may  be  first  recognized  on  chemical  examination  of  the 
stomach-contents.  In  other  cases  there  is  dilatation  with  its  accom- 
panying symptoms,  or  in  the  absence  of  dilatation  there  may  be  flatu- 
lency, eructation,  hiccough,  gastralgia,  nausea,  and  vomiting.  Intestinal 
indigestion  may  also  be  present,  with  diarrhea,  anemia,  and  nervousness. 
When  the  motor  activity  of  the  stomach  remains  normal  and  the  intes- 
tinal digestion  active,  the  condition  may  persist  for  years  without  greatly 
impairing  the  health  or  producing  emaciation. 

Diagnosis. — After  the  usual  test-breakfast,  the  stomach-contents  show 
an  entire  absence  of  HCl,  the  ferments  and  proteoses.  The  salivary 
digestion  is  sometimes  found  to  have  progressed  in  the  stomach.  The 
administration  of  HCl  with  the  test-meal  of  meat  is  not  followed  by 
evidence  of  digestion,  since  no  pepsin  is  secreted. 

Treatment— The  diet  should  consist  chiefly  of  vegetables  and  starchy 
food.  They  should  be  well  cooked  and  thoroughly  masticated,  or  arti- 
ficially divided  into  small  fragments.  Well-hashed  sweetbreads,  raw 
oysters,  and  chicken  may  be  occasionally  allowed  in  small  quantities.  A 
large  quantity  of  food  should  be  eaten  in  order  to  maintain  the  nourish- 
ment of  the  patient,  since  he  depends  solely  upon  intestinal  digestion. 
The  bitter  tonics  and  hydrochloric  acid  may  be  of  benefit.  An  active 
pepsin  may  also  be  given.  Lavage  with  a  weak  salt  solution,  followed 
by  faradization,  has  been  recommended. 

2.  NEUROSES  OF  MOTION. 

(<z)  Nervous  Eructations. — As  a  pure  neurosis,  eructation,  or  the 
belching  of  air,  is  common  in  hysterical  and  neurasthenic  women  and 
children.  An  entire  family  is  sometimes  affected  through  imitation.  The 
eructations  generally  occur  in  rapid  succession  and  produce  a  loud  noise. 
They  are  usually  maintained  by  the  involuntary  swallowing  of  air,  which 
has  been  attributed  to  a  spasm  of  the  esophagus.  The  condition  is 
commonly  associated  with  the  other  neuroses  and  with  many  patho- 
logical conditions  of  the  stomach,  especially  conditions  in  which  the 
stomach  does  not  discharge  its  contents  regularly  into  the  duodenum. 
A  spasm  of  the  pylorus  and  patulousness  of  the  cardia  are  supposed  to 
exist  in  some  cases. 

(<^)  Pneumatosis  is  a  condition  in  which  the  stomach  becomes  dis- 
tended with  gas,  which,  owing  to  weakness  of  its  muscular  coat,  it  is  not 
able  to  discharge.  The  gas  is  usually  derived  from  the  abnormal  fer- 
mentation of  food  or  it  may  be  regurgitated  from  the  intestine.  It 
usually  consists  of  carbon  dioxid,  nitrogen,  and  hydrogen;  but  other 
gases  may  be  present. 

Treatment  of  Eructation  and  Pneumatosis. — Remedies  are  usually  ad- 
ministered with  a  view  to  hastening  the  expulsion  of  the  gas  as  well  as 
to  prevent  its  formation.  Turpentine,  aromatic  spirit  of  ammonia, 
chloroform-water,  sodium  bicarbonate,  magnesia,  and  spirit  of  pepper- 
mint are  chief  among  the  former  class;  dilute  hydrochloric  acid  and 
tincture  of  nux  vomica  amons:  the  latter.    The  diet  should  be  for  a  time 


NEUROSES  OF  THE  STOMACH  473 

restricted  to  easily  digested  articles.     Pneumatosis  may  be  temporarily 
relieved  by  the  application  of  turpentine  stupes. 

(r)  Pyrosis  (Regurgitation,  Heartburn).— This  affection  occurs  much 
less  frequently  as  a  pure  neurosis  than  as  a  result  of  chronic  gastritis, 
superacidity,  or  dilatation  of  the  stomach,  or  obstruction  of  the  esoph- 
agus. Treatment  is  directed  to  the  general  nervous  state  or  the  under- 
lying pathological  condition. 

(^/)  Rumination  (merycismus)  is  a  rare  form  of  regurgitation  in 
which  the  food  is  voluntarily  raised  into  the  mouth  and  subjected  to  a 
second  mastication,  as  is  customary  with  some  of  the  lower  animals.  It 
is  usually  seen  in  hysterical,  idiotic,  or  epileptic  subjects.  It  may  be 
associated  with  achylia  gastrica,  as  in  the  case  recorded  by  Einhorn,  or 
with  other  neuroses.  The  treatment  is  that  of  the  nervous  condition, 
together  with  moral  suasion. 

(^)  Nervous  vomiting  sometimes  occurs  in  hysterical  or  neurasthenic 
persons,  independently  of  pathological  lesion  or  abnormal  gastric  con- 
tents. The  source  of  the  nervous  impulse  may  be  found  in  a  displaced 
uterus,  prolapsed  kidney,  or  localized  inflammation;  and  it  may  result 
from  injury.  It  is  seen  also  in  connection  with  nervous  diseases,  notably 
locomotor  ataxia.  It  is  commonly  observed  in  hysterical  women,  or  it 
may  follow  nervous  strain  or  mental  emotion.  The  initial  vomiting  of 
the  acute  infectious  diseases  is  probably  of  this  nature.  The  vomiting  is 
not  usually  preceded  by  nausea  or  accompanied  with  gagging  or  much 
apparent  effort.  Pallor  and  faintness  may  be  present  or  feigned  at  the 
beginning  of  the  attack.  The  attacks  recur  at  regular  intervals  and 
sometimes  persist  almost  without  interruption  for  several  days. 

(/)  Supermotility  (hyperkinesis)  is  an  increased  peristaltic  activity 
of  the  stomach,  the  chief  manifestation  of  which  is  a  premature  discharge 
of  the  contents  into  the  intestine.  Although  it  is  believed  to  be  primary 
and  of  nervous  origin  in  some  cases,  it  is  generally  a  sequence  of  super- 
secretion  or  superacidity.    No  definite  symptoms  are  produced. 

(^)  Peristaltic  unrest  is  a  name  given  by  Kussmaul  to  a  not  infre- 
quent form  of  supermotility  manifested  in  loud  gurgling  or  rumbling 
noises  (borborygmi).  The  peristalsis  is  usually  excited  by  taking  food, 
but  may  be  induced  by  the  emotions.  The  patient  can  often  feel  the 
peristaltic  movements.  In  some  cases  the  intestine  participates  in  the 
increased  activity,  and  occasionally  the  peristalsis  is  reversed. 

(/z)  Spasm  of  the  Cardia. — This  sometimes  results  from  such  slight 
irritation  as  a  cold  drink  or  from  the  passage  of  a  sound  in  a  hysterical 
person.  It  may  be  periodic  in  occurrence,  or  it  may  persist  for  several 
days.     Pneumatosis  sometimes  accompanies  the  tonic  spasm. 

(/)  Relaxation  of  the  cardia  is  occasionally  met  with  in  connection 
with  regurgitation,  eructation,  and  rumination. 

(y)  Spasm  of  the  pylorus  may  be  caused  by  reflex  influences  or  it 
may  result  from  superacidity,  ulcer,  or  gastric  catarrh.  When  persist- 
ent, it  occasions  retention  of  food,  fermentation,  and  dilitation  of  the 
stomach. 

(>^)  Relaxation  .of  the  pylorus,  or  pyloric  incontinence,  permits  the 
too  early  escape  of  the  gastric  contents  into  the  intestine.  The  food 
is  sometimes  passed  into  the  duodenum  immediately  after  entering  the 
stomach. 


474 


PRACTICE  OF  MEDICINE 


(/)  Atony  of  the  Stomach. — This  condition,  which  signifies  a  relaxed 
or  enfeebled  condition  of  the  muscular  coat  of  the  stomach-wall,  occurs 
as  a  neurosis  in  debilitated  or  neurasthenic  conditions  of  the  general 
system.  It  is  more  frequently  a  result  of  organic  disease,  produced  by 
habitual  overdistention  with  food  or  drink,  or  a  general  wasting  of  the 
tissues  of  the  body  from  chronic  disease.  It  sometimes  occurs  also  in 
connection  with  the  acute  infections,  especially  typhoid  fever.  The  symp- 
toms are  generally  those  of  dilatation,  especially  eructations  and  a  feel- 
ing of  distention  and  weight. 

Treatment  of  Motor  Neuroses. — In  addition  to  the  general  treatment  to 
be  considered,  little  is  usually  required.  When  the  activity  is  too  great, 
the  diet  must  be  of  the  mildest  kind,  free  from  irritating  or  stimulating 
properties;  but  deficient  motility  calls  for  highly  seasoned  food  and 
preferably  a  meat  diet,  with  the  administration  of  bitter  tonics.  The 
spasm  and  persistent  vomiting  sometimes  require  careful  treatment,  ab- 
stinence from  food  for  a  day,  followed  by  the  administration  of  small 
quantities  at  short  intervals  and  the  treatment  recommended  for  the 
vomiting  in  gastric  ulcer.  The  treatment  of  atony  is  practically  the 
same  as  that  for  dilatation  of  the  stomach. 

3.    NEUROSES   OF   SENSATION. 

(«)  Hyperesthesia. — In  this  condition  the  patient  complains  of  more 
or  less  distress  in  the  stomach,  with  a  burning  pain  in  the  epigastrium 
after  the  ingestion  of  food  or  drink.  In  all  other  respects  the  function 
of  the  stomach  is  normally  performed.  A  colored  fluid  taken  as  medicine 
may  not  occasion  discomfort.  The  aff^ection  is  met  with  in  the  same 
class  of  neurasthenic  or  hysterical  individuals,  mostly  women,  who  are 
the  subjects  of  the  other  neuroses.  It  may  follow  a  violent  emotion,  as 
fright  or  anger,  shock,  or  a  severe  illness,  as  the  influenza  or  an  infec- 
tious fever.  The  gastric  irritability  may  be  so  extreme  that  the  patient 
becomes  greatly  emaciated. 

(^)  Gastralgia,  or  gastrodynia,  may  occur  as  a  pure  neurosis,  inde- 
pendent of  organic  disease  or  the  ingestion  of  food,  and  often  seizing  the 
patient  at  night.  In  other  cases  it  is  associated  with  other  neurotic 
manifestations.  They  sometimes  accompany  menstrual  disorders,  possi- 
bly at  puberty,  but  more  particularly  at  the  menopause.  It  is  some- 
times associated  with  superacidity  or  supersecretion  and  may  occur  in 
neurasthenic  men.  Malaria  is  regarded  by  some  writers  as  a  possible 
cause.  The  gastric  crises  occurring  in  the  course  of  nervous  diseases, 
notably  in  locomotor  ataxia,  belong  to  this  group  of  affections. 

Symptoms. — The  pain  is  often  excruciating.  It  is  generally  most 
severe  in  the  epigastrium,  but  often  radiates  to  the  shoulders,  sides,  and 
back,  resembling  the  pain  of  ulcer.  It  is  usually  independent  of  the 
ingestion  of  food,  and  often  recurs  at  more  or  less  definite  intervals, 
frequently  awakening  the  patient  from  sleep.  Tenderness  may  be  elicited 
on  deep  pressure,  but  moderate  pressure  affords  relief.  Eructations, 
restlessness,  and  other  nervous  or  hysterical  manifestations  commonly 
accompany  the  attack.  Vomiting  seldom  occurs,  and  the  ingestion  of 
food  may  give  relief,  as  in  hyperchlorhydria. 

Diagnosis.— The  diagnosis  is  often  difficult,  especially  at  the  first  ex- 


NEUROSES  OF  THE  STOMACH  475 

amination  of  a  patient  not  previously  known.  The  seizure  must  be 
differentiated  from  gastric  ulcer  and  cancer,  bilious  and  renal  colic,  and 
angina  pectoris.  Ulcer  is  excluded  by  the  greater  periodicity  of  the 
attacks,  perhaps  by  the  absence  of  anemia.  Hematemesis  is  not  present; 
the  pain  radiates  over  a  wider  area,  and  the  taking  of  food  relieves, 
rather  than  aggravates,  it.  Ca?tcer  usually  occurs  at  a  more  advanced 
age,  the  pain  does  not  radiate  so  widely,  and  the  symptoms  are  not  so 
constant.  The  presence  of  a  cachexia  favors  cancer.  In  hepatic  colic  the 
pain  is  even  more  extreme,  and  it  is  confined  to  the  region  of  the  gall- 
bladder, where  tenderness  is  also  found.  The  presence  of  jaundice  and 
clay -colored  stools  is  highly  significant.  In  retial  colic  the  pain  is  lower 
in  the  abdomen  and  radiates  along  the  ureter  to  the  bladder  or  thigh. 
The  urine  is  highly  acid  and  often  contains  sand  or  gravel.  In  angina 
pectoris  the  pain  is  in  the  precordial  region,  often  radiating  to  the  left 
arm.  There  is  marked  dyspnea  with  a  sense  of  suffocation  and  impend- 
ing death. 

Treaiment. — If  the  attack  comes  on  soon  after  the  ingestion  of  a  full 
meal,  an  emetic  may  afford  relief;  if  during  the  night,  it  calls  for  the 
application  of  hot  fomentations,  the  hot-water  bottle,  or  a  mustard-leaf, 
and  internally  chloroform,  TTLxv  (i.o),  or  the  compound  spirit  of  sul- 
phuric ether.  Morphin  must  sometimes  be  given  hypodermically,  but  it 
should  be  avoided  if  possible,  for  this  class  of  patients  are  especially 
susceptible  to  the  habit.  Atropin  should  be  combined  with  it.  It  is 
sometimes  necessary  to  keep  the  patient  on  a  milk  diet  for  several  weeks, 
with  the  administration  of  the  general  remedies  for  the  neurotic  condition 
in  order  to  overcome  the  tendency  to  the  attacks. 

((t)  Anorexia,  or  the  absence  of  appetite,  is  associated  with  so  many 
conditions,  as  a  neurosis  or  otherwise,  that  it  requires  no  special  con- 
sideration. It  is  a  common  result  of  febrile  disease,  but  it  is  also  met 
with  in  hysteria  and  neurasthenia.  The  administration  of  the  bitter 
tinctures,  or  strychnin  and  arsenic,  is  generally  beneficial. 

(</)  Bulimia,  hyperorexia,  and  polyphagia  are  terms  applied  to  a 
ravenous  appetite  or  constant  sense  of  hunger ;  and  akoria  signifies  an 
absence  of  the  sense  of  satiety  after  a  full  meal.  The  conditions  may  be 
constant,  but  usually  occur  periodically.  They  are  seen  especially  in 
connection  with  the  psychoses,  sometimes  in  hysteria,  epilepsy,  idiocy, 
cerebral  tumors,  and  occasionally  in  exophthalmic  goiter.  They  some- 
times occur  during  pregnancy,  and  may  be  associated  with  superacidity. 
Hunger  may  continue  after  a  full  meal,  or  the  patient  may  be  awakened 
during  the  night  with  a  sense  of  faintness  from  hunger.  A  similar  ex- 
aggeration of  appetite  often  accompanies  convalescence  from  prolonged 
illness,  especially  typhoid  fever,  and  it  is  a  common  symptom  of  early 
diabetes. 

(^)  Parorexia  signifies  a  perverted  appetite.  It  is  more  commonly 
met  with  in  the  insane,  sometimes  in  the  hysterical,  occasionally  in 
pregnant  women.  Such  articles  as  chalk,  slate-pencils,  clay,  salt,  and 
baking-soda  are  commonly  craved.  This  condition  is  sometimes  called 
pica.  When  the  patient  loathes  ordinary  food  and  craves  highly  seasoned 
articles,  pickles  and  spices,  it  is  sometimes  spoken  of  as  malacia. 

General  Treatment  of  Gastric  Neuroses. — The  treatment  of  the  general 
physical  and  mental  condition  of  the  patient  is  more  important  than 


476  PRACTICE  OF  MEDICINE 

that  of  the  gastric  disturbance  itself.  The  occupation  and  habits  may 
be  at  fault.  Many  cases  are  observed  in  individuals  occupied  so  many 
hours  during  the  day  that  they  have  no  time  for  rest  and  recuperation; 
other  cases  can  be  attributed  to  a  too  ardent  devotion  to  society.  In 
either  condition  a  change  to  outdoor  exercise,  athletic  sports,  and  games 
often  produces  immediate  improvement.  A  vacation  of  a  month  or  two 
in  the  country,  or  a  sea-voyage,  is  all  that  is  required.  Complete  rest 
of  mind,  with  bodily  exercise,  is  generally  best.  The  diet  should  be  regu- 
lated according  to  the  special  condition  as  already  noted  under  the 
different  forms  of  neuroses.  In  the  conditions  that  lead  to  dilatation  or 
atony  of  the  gastric  walls,  stimulating  food  and  bitter  tonics  should  be 
prescribed.  The  nitrate  of  silver  is  often  useful,  and  lavage  may  prove 
beneficial.  The  anemia  which  is  often  present  calls  for  iron,  arsenic,  and 
nutritious,  easily  digestible  food,  with  exercise  in  the  open  air.  Con- 
stipation is  common  and  should  be  met  with  laxatives.  When  intestinal 
indigestion  accompanies  the  gastric,  as  it  often  does,  it  may  be  necessary 
to  regulate  the  diet  still  more  rigidly  and  to  administer  intestinal  anti- 
septics. Cases  in  which  insomnia  proves  troublesome  require  the  bromids 
or  a  narcotic,  as  trional,  gr.  xv  (i.o),  at  night.  The  Weir  Mitchell 
treatment— confining  the  patient  to  bed  on  a  graduated  milk  diet,  with 
massage,  for  a  month  or  six  weeks— is  often  a  most  successful  method  in 
hysterical  cases. 

DISEASES  OF  THE  INTESTINES. 
ACUTE  CATARRHAL  ENTERITIS. 

DIARRHEA,  ACUTE  INTESTINAL  CATARRH,  ILEOCOLITIS. 

Definition.— An  acute  catarrhal  inflammation  involving  a  greater  or 
less  portion  of  the  intestinal  tract.  Although  the  disease  is  perhaps 
limited  in  some  instances  to  a  single  region  of  the  intestine,  such  distinc- 
tions as  duodenitis,  jejunitis,  and  ileitis,  or  other  anatomical  classification 
is  not  practicable. 

Etiology. — The  disease  is  a  very  common  one,  affecting  individuals  of 
any  age,  but  particularly  infants  and  children.  It  may  be  primary  in 
character,  or  it  may  occur  secondarily  in  the  course  of  other  affections. 
A  tendency  to  recurrence  develops  as  a  result  of  repeated  attacks.  Per- 
sonal idiosyncrasy  is  also  an  important  factor,  and  in  many  persons 
certain  articles  of  food  invariably  produce  diarrhea,  i.  The  most  fre- 
quent causes  of  primary  enteritis  are :  («)  Errors  in  diet ;  the  eating  of 
food  that  is  improper  in  quality  or  excessive  in  quantity.  Unripe  and 
overripe  fruit,  decomposed  meats,  sour  milk,  or  food  containing  organic 
or  mineral  poisons,  especially  canned  meats  and  fruits,  are  common 
sources  of  offense. 

((5)  Impure  drinking-water  is  an  occasional  cause  of  epidemic  out- 
breaks. Mere  change  of  drinking-water  necessitated  in  travel  often  pro- 
duces diarrhea. 

(0  Toxic  substances.  The  free  or  prolonged  use  of  such  drugs  as 
arsenic,  acids,  alkalis,  mercury,  iodids,  antimony,  or  colchicum  and  other 
vegetable  preparations  may  induce  the  disease. 


ACUTE  CATARRHAL  ENTERITIS  47.7 

(a^)  Alterations  in  the  chemical  composition  of  the  intestinal  secre- 
tion, as  through  the  absence  of  the  pancreatic  juice,  an  increase  or  de- 
crease in  the  quantity  of  bile.  Arrest  of  the  pancreatic  secretion  usually 
produces  fatty  diarrhea. 

(i?)  A  common  cause,  affecting  especially  certain  individuals,  is  chill- 
ing of  the  surface  of  the  body,  particularly  of  the  abdomen,  through 
change  of  weather,  exposure  to  cold  and  wet,  or  sleeping  in  a  draft. 

(/)  A  nervous  origin  may  be  traced  in  many  cases,  especially  when 
the  attack  follows  fright  or  other  strong  emotion;  such  attacks  are 
occasionally  met  with  in  students  under  the  strain  of  an  impending 
examination.     (See  Nervous  Diarrhea,  p.  508.) 

2.  The  usual  causes  of  secondary  enteritis  are  :  (^a)  Conditions  of  the 
stomach  which  cause  the  passage  of  undigested  or  fermenting  food  into 
the  intestine. 

((5)  Various  acute  infections,  as  typhoid  fever,  malaria,  dysentery, 
cholera,  tuberculosis,  and  sepsis,  affecting  the  bowel  through  structural 
changes  or  the  production  of  toxins. 

(r)  The  extension  of  inflammation  to  the  bowel  from  adjacent  struc- 
tures as  in  peritonitis  of  different  forms,  or  from  a  focus  of  ulceration, 
malignant  disease,  hernia,  or  other  strangulation. 

(rt^)  Disturbance  of  the  circulation  such  as  results  from  chronic  disease 
of  the  heart  or  lungs,  but  more  particularly  of  the  portal  circulation  in 
hepatic  cirrhosis,  or  through  the  pressure  of  tumors  on  the  portal  or 
mesenteric  veins. 

(^e)  A  secondary  diarrhea  sometimes  follows  extensive  burns.  Diar- 
rhea is  often  produced  also  by  influences  which  merely  hasten  the  peri- 
stalsis. 

Morbid  Anatomy. — The  intestine  during  life,  as  occasionally  seen  at  ab- 
dominal section,  appears  red  and  swollen,  and  the  secretion  of  mucus 
is  increased;  but  the  evidences  of  hyperemia  usually  disappear  after 
death.  The  solitary  and  agminated  follicles  are  often  enlarged,  and  they 
may  show  a  variable  degree  of  ulceration,  particularly  in  children.  Des- 
quamation of  the  surface  epithelium  is  seen,  but  probably  as  a  post- 
mortem change. 

Symptoms. — Diarrhea  is  the  most  characteristic  symptom,  yet  it  is 
not  invariably  present.  The  onset  of  the  disease  is  frequently  announced 
within  an  hour  or  two  after  the  ingestion  of  improper  food.  The  indi- 
vidual may  be  suddenly  aroused  from  sleep  by  an  intense  colic  or  tenes- 
mus, sometimes  accompanied  with  cramping  of  the  abdominal  or  leg 
muscles.  Gurgling  or  rumbling  noises  (borborygmi)  are  heard  in  the 
abdomen.  The  pain  recurs  at  short  intervals  until  there  is  an  imperative 
desire  to  evacuate  the  bowel.  When  the  pain  is  severe  and  when  the 
irritation  affects  also  the  stomach,  nausea  and  vomiting  precede  or 
accompany  the  diarrhea.  The  abdomen  is  generally  tympanitic.  The 
pain  is  often  so  intense  that  the  patient  bends  over,  presses  a  pillow 
against  the  abdomen,  or  rolls  from  side  to  side  in  efforts  to  obtain  relief. 
It  is  usually  intermittent  and  relieved  by  the  evacuation  of  the  bowel. 
Thirst  is  extreme,  and  the  gratification  of  it  induces  or  prolongs  the 
vomiting.  Fever  is  uncommon,  but  there  may  be  a  slight  elevation  of 
temperature,  particularly  in  children.  With  profuse  diarrhea  the  tempera- 
ture may  become  slightly  subnormal.    The  stools  vary  greatly  in  fre- 


478  PIL\CTICE  OF  MEDICIXE 

quency,  appearance,  and  consistence.  They  are  sometimes  thin  as  water 
and  contain  mucus  or  undigested  food.  When  food  appears  in  them,  the 
condition  is  called  lienteric  diarrhea.  The  attack  usually  lasts  only  a 
day  or  two,  but  it  may  be  prolonged  for  a  week  or  longer. 

Diagnosis.— It  is  important,  with  reference  to  treatment,  to  determine 
whether  the  disease  is  situated  in  the  large  or  small  intestine.  When  the 
small  bowel  is  alone  affected,  the  diarrhea  is  not  usually  so  profuse,  but 
the  pain  is  more  persistent  and  of  a  colick}"  character;  there  may  be 
gurgling,  but  seldom  borborygmi.  The  stools  are  more  watery,  yellow- 
ish, green  or  grayish  in  color,  and  often  lienteric.  They  do  not,  as  a 
rule,  contain  mucus.  WTien  the  large  bowel  alone  is  affected,  pain  may 
be  absent,  or  it  precedes  and  accompanies  the  dejection.  The  occurrence 
of  tenesmus  indicates  an  involvement  of  the  lower  portion  of  the  bowel. 
The  stools  are  of  uniform  consistence  and  they  usually  contain  mucus, 
either  in  flakes  or  in  large  masses.  Involvement  of  the  duodenwfi  is  to 
be  inferred  only  when  the  attack  follows  an  acute  gastritis  or  when 
jaundice  develops  as  a  result  of  the  extension  of  the  inflammation  into 
the  common  bile-duct. 

Cholera  nostras  is  distinguished  by  the  more  profuse  watery  discharges 
and  greater  prostration  which  attend  it. 

Prognosis. — Primary  cases  usually  recover  promptly,  but  secondary 
cases,  especially  when  due  to  tuberculosis  or  cachectic  conditions,  gener- 
ally pass  into  a  chronic  form. 

Treatment. — Rest  is  all  that  is  required  in  most  cases.  The  patient 
should  remain  in  bed  and  abstain  from  food  or  take  only  milk  with  lime- 
water  or  carbonated  water  in  small  quantities  for  24  to  48  hours.  If 
the  pains  are  extremely  severe,  a  hypodermic  dose  of  morphin  may  be 
given.  It  is  not  well  to  check  the  diarrhea  until  the  intestine  has  been 
thoroughly  evacuated.  If  only  a  few  small  dejections  have  taken  place, 
calomel,  gr.  iij  (0.2),  castor  oil,  3]  (30.0),  or  a  bottle  of  effervescent 
magnesium  citrate  should  be  given.  This  may  be  followed  with  a  few 
doses  of  bismuth,  gr.  x  (0.65),  and  opium,  gr.  ^  (0.016),  or  the  campho- 
rated tincture,  3j  (3.5).     The  thirst  should  be  relieved  with  chipped  ice. 

The  secondary  diarrhea  is  often  difilicult  of  treatment,  especially  when 
it  is  due  to  tuberculosis  or  other  chronic  disease.  (See  Tuberculosis  of 
the  Intestine.)  When  the  disease  is  confined  to  the  large  bowel,  a  copious 
enema  checks  it  immediately  in  most  cases.  Opiates  are  not  usually 
required,  but,  for  the  relief  of  pain,  starch-water,  3  ij  (6c. o),  containing 
tr.  opii,   TT^xx  (1.2),  may  be  injected  into  the  rectum. 

CHRONIC   CATARRHAL  ENTERITIS. 

CHRONIC   DIARRHEA,  CHRONIC  INTESTINAL  CATARRH.  CHRONIC  COLITIS. 

Definition.— Chrorvic  catarrhal  inflammation  of  a  greater  or  less  por- 
tion of  the  small  and  large  intestine. 

Etiology. — The  disease  often  results  from  repeated  attacks  or  from  a 
single  prolonged  attack  of  the  acute  form  of  enteritis;  all  the  causes 
which  are  operative  in  that  form  are,  therefore,  indirectly  the  causes  of 
this.  In  most  cases,  however,  the  disease  is  directly  due  to  other  chronic 
disease,  as  tuberculosis,  malaria,  cirrhosis  or  passive  congestion  of  the 


CHRONIC   CATARRHAL  ENTERITIS  479 

liver.  Tubercular  or  cancerous  ulceration  of  the  bowel  is  attended  with 
chronic  diarrhea.  The  disease  sometimes  develops  also  in  the  course  of 
chronic  nephritis,  diabetes,  or  gout.  Damp  dwellings  and  prolonged  ex- 
posure, with  insufficient  nourishment,  as  in  camps  and  prisons,  are  com- 
mon causes. 

Morbid  Anatomy. — When  the  disease  has  lasted  only  a  comparatively 
short  time,  the  changes  may  be  slight,  but  later  there  are  usually  found 
hyperemia,  ecchymosis,  thickening  of  the  mucous  membrane,  and  very 
often  a  more  or  less  extensive  ulceration  affecting  especially  the  follicles. 
The  intestine  may  be  uniformly  or  irregularly  dilated  or  contracted,  and 
fecal  accumulations  are  sometimes  found.  The  great  thickening  of  the 
mucous  membrane  sometimes  produces  stenosis ;  and  the  same  result  may 
follow  the  cicatrization  of  ulcers.  The  mucous  membrane  has  usually  a 
reddish  brown  or  grayish  color ;  occasionally  it  is  black,  or  the  pigment 
may  be  deposited  in  the  tops  of  the  villi,  around  the  circumference  or  in 
the  center  of  the  follicles.  When  in  the  last  of  these  locations,  the  mucous 
membrane  has  the  so-called  shaved-beard  appearance.  The  lesions  are 
usually  most  pronounced  in  the  lower  portion  of  the  ileum  and  in  the 
colon.  The  increased  activity  of  the  secreting  glands,  together  with  the 
ulceration,  produces  an  increased  quantity  of  fluid  in  the  intestine,  which 
is  usually  of  a  thinner  consistence  than  normal  and  often  serous,  san- 
guinolent,  or  purulent  in  character. 

Symptoms. — Diarrhea  is  the  important  symptom,  but  it  frequently 
alternates  with  constipation.  As  a  rule,  from  one  to  six  or  eight  thin 
dejections  occur  in  24  hours;  frequently  they  occur  only  in  the  morning. 
They  may  be  large  or  small  in  quantity,  semisolid  or  watery,  sometimes 
containing  undigested  food  and  varying  in  color  from  a  pale  yellow, 
green,  or  white  to  reddish  brown  or  black.  Pain  and  borborygmi,  with 
abdominal  distention,  tenderness,  and  flatulence,  are  frequent  accompani- 
ments. If  the  stomach  be  also  involved,  there  are  anorexia,  pyrosis,  a 
disagreeable  taste,  and  the  tongue  is  heavily  coated  or  red,  glazed,  and 
fissured.  The  patient  often  becomes  extremely  emaciated,  marasmic, 
weak,  and  hypochondriacal  or  melancholic.  Fever  usually  develops  to- 
ward the  close  of  a  fatal  case. 

Diagnosis. — The  recognition  of  the  disease  is  easy,  but  the  determina- 
tion of  the  part  of  the  bowel  that  is  affected  may  be  quite  difficult,  in 
part  because  the  disease  is  seldom  limited  to  a  single  region.  Affection 
of  the  duodenum  is  probable  when  there  is  jaundice,  and  when  the  stools 
are  fatty  or  have  a  clay  color.  In  affection  of  the  jejunum  and  ileum 
there  is  usually  pain  at  the  umbilicus  a  few  hours  after  taking  food,  but 
pain  may  be  entirely  absent;  the  diagnosis  is  never  sure.  Colitis  is 
characterized  by  large  stools  and  severe  pain,  often  just  before  a  move- 
ment. Catarrh  of  the  rectum  (^proctitis)  is  generally  indicated  by  fre- 
quent painful  dejections  and  a  constant  desire  for  evacuation.  Ulcera- 
tion is  indicated  by  extreme  localized  tenderness  and  the  discharge  of 
pus  or  blood  or  of  portions  of  the  mucous  membrane. 

Prognosis. — The  disease  is  persistent,  and  it  often  proves  fatal  in 
children  or  aged  and  debilitated  subjects.  When  not  promptly  treated, 
it  may  last  for  months  or  years.  Death  usually  results  from  exhaustion, 
intercurrent  bronchitis,  pneumonia,  peritonitis,  thrombosis  of  the  cerebral 
sinuses,  or  other  disease.     Relapse  is  common  after  apparent  recovery. 


48o  PRACTICE  OF  MEDICINE 

Treatment. — Dietetic  and  hygienic  measures  are  all-important.  In 
many  cases  an  absolute  milk  diet,  preferably  predigested,  for  a  few 
weeks  is  advisable.  This  may  be  followed  with  eggs  and  articles  made 
with  milk,  eggs,  and  corn-starch,  rare  beef,  junket,  toast,  and  rice;  but 
an  excess  of  starch  must  be  avoided.  Fats,  sweet  fruits,  pastry,  and 
alcoholic  beverages  should  be  avoided.  Light  exercise  in  the  open  air 
and  an  abundance  of  sunshine,  with  rest  from  mental  worriment,  are 
important.  These  patients  should  be  warmly  clad,  and  a  flannel  ab- 
dominal band  is  often  beneficial.  Pancreatin,  gr.  v  (0.32),  should  be 
given  with  the  meals,  and  salol,  gr.  v  to  x  (0.32 — 0.65),  or  bismuth 
subgallate,  gr.  xx  (1.30),  two  or  three  hours  after.  Calomel  or  castor 
oil  should  be  occasionally  administered  to  cleanse  the  bowel,  especially 
when  there  are  intervals  of  constipation.  Silver  nitrate,  gr.  %,  in  kera- 
tin-coated pills,  is  often  beneficial  in  persistent  cases.  When  the  disease 
is  located  in  the  descending  colon,  a  daily  irrigation  with  a  warm  salt 
or  alum  solution  (i  per  cent)  or  silver-nitrate  solution  (0.5  per  cent) 
is  often  curative.  Codliver  oil,  iron,  and  arsenic  may  be  given  for  the 
anemia  and  emaciation.  Opium  should  be  avoided  except  in  a  hopeless 
case. 

CHOLERA  MORBUS. 

CHOLERA  NOSTRAS. 

Definition. — An  acute  catarrh  of  the  stomach  and  intestines  in  adults, 
presenting  symptoms  resembling  in  severity  those  of  Asiatic  cholera. 

Etiology. — The  disease  is  probably  due  to  a  specific  microbe  which  has 
not  yet  been  isolated.  It  occurs  especially  during  the  late  summer, 
when  the  days  are  excessively  hot  and  the  nights  cold.  It  affects  com- 
monly young  adults,  though  it  may  attack  persons  of  any  age.  It  is 
generally  attributed  to  errors  in  diet  of  the  same  character  as  cause 
acute  catarrhal  enteritis,  but  epidemic  outbreaks  are  not  unusual. 

Morbid  Anatomy. — The  lesions  are  those  of  acute  gastritis  combined 
with  those  of  acute  enteritis;  a  catarrh  of  the  entire  intestinal  tube. 
The  walls  axe  swollen  and  edematous,  the  follicles  enlarged  and  abnor- 
mally active.  In  severe  cases  the  appearances  are  much  the  same  as 
in  cholera,  except  that  the  comma  bacillus  is  not  found. 

Symptoms. — The  onset  is  usually  sudden,  but  in  some  instances  it  is 
preceded  by  malaise,  loss  of  appetite,  and  nausea.  The  attack  frequently 
begins  at  night  with  severe  abdominal  pain  or  tension,  nausea,  and  re- 
peated vomiting.  After  the  food  has  been  ejected,  the  vomit  consists  of 
thin,  serous,  often  bile-stained  fluid.  Purging  develops  either  with  it 
or  shortly  afterward.  The  stools  are  at  first  feculent,  but  later  become 
watery,  almost  odorless  and  colorless,  and  often  assume  the  typical 
rice-water  appearance.  Both  the  vomiting  and  purging  are  often  violent 
and  almost  incessant.  Severe  abdominal  pains  follow  each  spell  of 
vomiting  and  purging,  and  cramps  and  twitching  of  the  muscles  of  the 
calves  often  occur.  There  is  intense  thirst,  scant,  sometimes  albuminous 
urine  or  anuria.  The  skin  becomes  cold,  cyanotic,  and  clammy ;  the  ema- 
ciation is  often  so  rapid  that  within  a  day  or  two  the  eyes  become 
sunken,  the  cheeks  hollow,  and  the  nose  pinched.  The  patient  appears 
to  shrivel  and  waste  away  as  in  true  cholera.    All  these  changes,  includ- 


CHOLERA  MORBUS  4§i 

ing  the  muscular  cramps,  are  attributed  to  the  withdrawal  of  water 
from  the  blood  and  tissues.  Fever  is  seldom  present  and  it  rarely  ex- 
ceeds a  degree  or  two.  In  severe  cases  the  patient  sinks  into  a  collapse ; 
the  pulse  becomes  extremely  feeble  and  rapid,  the  voice  weak,  and  the 
respiration  sighing,  but  the  mind  often  remains  clear.  Death  may  occur 
within  the  first  forty-eight  hours,  or  after  three  or  four  days,  from 
exhaustion.  In  most  cases,  however,  the  attack  lasts  only  one  or  two 
days,  then  subsides,  leaving  the  patient  greatly  prostrated,  but  recovery 
is  complete  within  a  week  or  two. 

Diagnosis. — In  the  absence  of  Asiatic  cholera,  the  disease  is  readily 
recognized  through  the  severity  of  its  symptoms.  During  a  cholera 
epidemic,  however,  cases  of  this  character  are  often  mistaken  for  that 
disease.  They  are  to  be  excluded  only  by  the  absence  of  the  cholera 
spirillum  from  the  stools. 

Prognosis. — The  mortality  is  trifling  in  previously  healthy  persons. 
In  the  very  young  or  very  aged,  and  in  those  debilitated  by  previous 
disease,  however,  it  is  often  fatal. 

Treatment.— Mor^hm  should  be  promptly  administered  hypodermi- 
cally,  and  hot  applications  should  be  made  to  the  abdomen  and  extremi- 
ties. A  mixture  containing  morphin,  chloroform,  ether,  and  spirit  of 
peppermint  ("chlorodin")  is  much  employed  internally.  Stimulants, 
especially  brandy  and  strychnin,  are  indicated.  The  thirst  may  be  re- 
lieved with  fragments  of  ice,  and  by  the  injection  of  salt  solution  into 
the  bowel  or  subcutaneously.  Milk  with  lime-water  should  be  the  only 
diet  for  several  days. 

ENTERITIS  IN  CHILDREN. 

ACUTE  GASTROENTERITIS,   SUMMER  DIARRHEA,  ACUTE  DYSPEPTIC 

DIARRHEA. 

Etiology.— This  is  the  common  form  of  summer  diarrhea  and  is  par- 
ticularly frequent  in  bottle-fed  infants.  It  is  especially  liable  to  occur 
in  those  raised  at  the  breast,  about  the  time  of  weaning.  It  is  often  seen 
also  at  the  time  of  the  irruption  of  the  teeth,  although  it  is  denied  by 
some  writers  that  this  normal  process  can  be  in  any  degree  responsible 
for  a  pathological  one.  As  a  rule,  the  disease  follows  directly  upon  a 
palpable  error  in  the  feeding  of  the  infant,  as  that  of  nursing  too  much 
or  too  often,  or  the  mother's  milk  may  be  unfit  on  account  of  ill-health, 
intemperance,  anger,  or  other  emotions.  Bottle-fed  infants  are  often 
given  food  that  is  unsuitable  for  their  age  and  digestive  power,  or  the 
food  is  given  too  often,  in  too  great  quantity,  at  an  improper  tempera- 
ture, or  after  it  has  soured  in  the  bottle.  All  these  influences  and  many 
more  contribute  to  the  production  of  the  disease.  A  feeble  constitution, 
rickets,  faulty  hygiene,  including  overcrowding,  lack  of  air  and  sunshine, 
filth,  exposure  to  cold  and  wet,  and  neglect,  exert  an  important  influ- 
ence in  many  cases.  In  older  children  the  attack  often  follows  the  eat- 
ing of  unripe  fruit. 

In  many  cases,  if  not  in  all,  the  disease  is  directly  due  to  the  presence 
of  bacteria  or  their  chemical  products  in  the  food.  The  studies  of  Messrs. 
Duval  and  Bassett  in  1902  indicate  that  the  disease  is  probably  due 
in  most  cases  to  the  Bacillus  dysenterioe  of  Shiga.     This  organism  was 

31 


482  PRACTICE  OF  MEDICINE 

found  in  the  stools  of  more  than  forty  cases,  in  large  numbers  in  the 
acute  and  less  numerously  in  mild  or  chronic  cases.  They  found  also 
that  the  blood  of  the  infants  affected  with  the  disease  possesses  an  agglu- 
tinative power  over  this  bacillus. 

Morbid  Anatomy. — The  lesions  found  after  death  are  limited  to  hy- 
peremia with  swelling  and  increased  secretion ;  ulceration  does  not  occur. 

Symptoms. — The  attack  may  be  ushered  in  with  vomiting  or  diarrhea. 
In  some  cases  the  infant  appears  restless  or  gives  other  evidences  of 
pain  for  a  few  hours  before  the  onset,  and  convulsions  occasionally 
occur.  The  dejections  become  rapidly  more  frequent  until  six  or  eight, 
often  twice  this  number,  may  occur  in  twenty-four  hours.  They  are  usu- 
ally large,  pasty,  and  offensive;  sometimes  they  are  frothy  and  sour- 
smelling.  They  generally  contain  undigested  milk,  and,  after  the  first 
day  or  two,  they  become  green.  The  tongue  is  coated  and  dry,  and  the 
infant  suffers  from  thirst.  There  is  not  usually  much  fever,  but  in  se- 
vere cases  the  temperature  may  rise  to  104°  or  105°  F.  (40° — 40.5°  C). 
The  cases  differ  in  severity  to  a  very  great  extent.  The  disease  some- 
times passes  into  an  ileocolitis  of  greater  or  less  duration. 

Diagnosis. — The  affection  is  differentiated  from  cholera  infantum  chiefly 
by  the  character  of  the  stools,  which  have  not  the  serous,  watery  quali- 
ties of  those  of  the  latter  disease.  From  ileocolitis  it  is  distinguished  by 
the  absence  of  mucus  and  blood  from  the  dejections. 

The  prognosis  is  usually  favorable  except  in  feeble  infants  or  those 
debilitated  through  neglect,  improper  food,  or  previous  disease.  The 
attack  lasts  from  three  to  seven  days,  but  relapses  are  common. 

Treatment. — The  promptest  relief  is  often  afforded  by  thorough  irriga- 
tion of  the  stomach,  or  of  both  stomach  and  bowel,  with  lukewarm 
water.  The  most  important  item  in  other  respects  is  the  adoption  of 
a  suitable  diet.  In  young  bottle-fed  infants  this  is  sometimes  difficult. 
Pure  cow's  milk,  properly  diluted  for  the  age,  is  safest,  unless  a  suitable 
wet-nurse  can  be  obtained.  When  the  stools  are  offensive,  albuminous 
food  should  be  withheld,  and  carbohydrates  in  the  form  of  dextrin  may 
be  added  to  the  milk;  when  the  stools  are  frothy  and  sour,  showing 
acid  fermentation,  the  carbohydrates  must  be  withheld,  and  nitrogenous 
food,  beef-juice,  or  albumen-water  may  be  given.  The  limiting  of  the 
diet  to  albumen- water,  with  a  teaspoonful  of  brandy  to  each  eight  ounces, 
is  often  necessary  for  a  few  days.  As  soon  as  the  diarrhea  subsides, 
milk  and  broth  may  be  allowed.  Great  care  must  be  exercised  in  the 
giving  of  water,  since  an  excess  keeps  up  the  vomiting,  and  thirst  is 
urgent. 

The  hygienic  management  of  the  case  is  equally  important.  The 
child  should  be  kept  in  a  cool,  well-ventilated  room  or  removed  from 
the  close  apartments  of  the  tenement-house,  where  most  cases  occur. 
It  should  be  kept  constantly  in  the  open  air,  day  and  night,  except  per- 
haps during  the  heat  of  the  afternoon,  but  it  must  not  be  carried  in 
the  arms.     If  circumstances  permit,  it  should  be  taken  to  the  countr}\ 

In  older  children  a  purgative  dose  of  calomel  or  castor  oil  is  indi- 
cated in  the  beginning,  and  this,  with  regulation  of  the  diet,  is  generally 
all  that  is  required.  The  diarrhea  usually  ceases  spontaneously  in  twenty- 
four  to  forty-eight  hours;  otherwise,  or  if  it  be  severe,  bismuth  in  large 
doses  (gr.   x;   0.65)   every  three  hours,  with  camphorated  tincture  of 


CHOLERA  INFANTUM  485 

opium  according  to  age,  may  be  given.  Intestinal  antiseptics,  particularly 
salol,  resorcin,  naphthalin,  and  sodium  salicylate,  are  recommended  by 
some  writers, 

CHOLERA  INFANTUM. 

Definition.— A  severe,  acute  gastrointestinal  catarrh,  probably  of  bac- 
terial origin,  and  characterized  by  a  profuse  serous  diarrhea  with  ex- 
treme prostration  and  rapid  loss  of  weight, 

Etioifogy.— The  disease  is  not  a  frequent  one,  and  there  can  be  little 
doubt  that  it  is  due  to  the  action  of  micro-organisms,  if  not  to  a  spe- 
cific microbe.  The  investigations  of  Duval  and  Bennett  in  this  connec- 
tion will  doubtless  prove  of  much  value.  The  disease  commonly  occurs 
in  the  same  class  of  improperly  fed,  poorly  nourished  infants  and  under 
the  same  faulty  hygienic  conditions  as  have  been  referred  to  in  the 
etiology  of  gastroenteritis.  It  seldom  develops  in  healthy  infants  under 
normal  conditions. 

Symptoms. — In  most  cases  the  actual  onset  of  the  disease  is  preceded 
by  a  short  attack  of  gastroenteritis  or  ileocolitis,  with  pain  and  rest- 
lessness. In  other  cases  there  is  sudden  prostration,  with  gradual  rise 
of  temperature  for  a  few  hours,  during  which  time  the  infant  may  give 
evidence  of  nausea  and  profound  illness.  Vomiting  and  purging  then 
set  in  with  violence,  and  recur  at  short  intervals.  After  the  stomach 
contents  have  been  discharged,  the  vomitus  consists  of  serum  and  mucus, 
which  soon  becomes  tinged  with  bile.  All  food  and  drink  are  generally 
immediately  ejected.  The  stools  are  large  and  watery;  at  first  pale 
green  or  yellow  and  offensive,  they  soon  lose  their  color  and  odor  and 
consist  almost  entirely  of  serum.  They  may  recur  at  intervals  of  a 
half-hour  or  less.  They  are  at  first  acid  in  reaction,  but  later  often 
become  alkaline.  The  microscope  reveals  in  them  much  epithelium  and 
numerous  bacteria.  The  child  becomes  rapidly  emaciated,  pale,  and 
bloodless  in  appearance,  the  anterior  fontanel  is  depressed,  and  the 
abdomen  is  retracted.  The  tongue  is  at  first  coated,  but  it  becomes 
red  and  dry,  and  the  thirst  is  extreme.  The  urine  is  scant  and  not 
infrequently  suppressed.  The  rectal  temperature  is  elevated,  but  the 
surface  is  often  cold.  The  infant  ceases  to  cry,  through  weakness,  or 
its  efforts  are  inaudible.  Collapse  usually  develops  early.  The  restless- 
ness of  the  early  stage  gives  way  to  a  semicomatose  condition,  in  which 
the  child  lies  with  half-open  eyes,  breathing  rapidly,  often  irregularly, 
with  little  remaining  evidence  of  life.  The  Cheyne-Stokes  respiration 
sometimes  develops,  and  there  may  be  retraction  of  the  head  as  in 
hydrocephalus  ("hydrencephaloid").  Convulsions  sometimes  occur,  or 
a  condition  of  tetany  may  develop.  The  temperature  often  becomes 
very  high  shortly  before  death,  sometimes  reaching  106°  or  108°  F, 
(41° — 42°  C).  When  recovery  is  about  to  occur,  the  vomiting  ceases 
and  the  stools  become  less  frequent,  finally  acquiring  their  normal  con- 
sistence and  color.    Convalescence  is  usually  slow. 

Diagnosis. — The  diagnosis  is  not  difficult,  but  the  distinction  between 
cholera  infantum  and  gastroenteritis  is  perhaps  too  often  neglected. 
The  distinctive  features  of  the  former  disease  are  the  constant  vomiting, 
profuse  serous   dejections,  thirst,  high  fever,  profound  prostration,  and 


'484  PRACTICE  OF  MEDICINE 

collapse.  It  is  the  severest  and  most  rapidly  fatal  form  of  intestinal  dis- 
ease in  infants. 

Prognosis. — Fully  two-thirds  of  the  cases  are  fatal,  regardless  of  the 
condition  of  the  patient  or  the  treatment  adopted.  The  disease  is  natu- 
rally most  fatal  in  debilitated,  unhealthy  children,  but  a  great  deal  de- 
pends upon  the  severity  of  the  attack.  Death  or  recovery  may  occur 
in  the  first  two  or  three  days,  and  the  initial  symptoms  generally  reveal 
the  prognosis. 

Treatment. — Prompt  measures  are  demanded.  Excellent  results  are 
often  obtained  from  thorough  irrigation  of  the  stomach  and  large  bowel. 
Since  nothing  can  be  retained  in  the  stomach,  hypodermic  medication 
should  be  resorted  to.  Morphin,  gr.  i-ioo  (0.0006),  and  atropin, 
gr.  1-800  (0.00008),  may  be  given  to  an  infant,  and  repeated  in  an 
hour  or  two  if  vomiting  and  purging  do  not  cease.  The  result  is  often 
remarkable,  but  the  action  of  the  morphin  must  be  carefully  watched 
until  the  tolerance  of  the  little  patient  has  been  determined.  It  must 
not  be  administered  in  a  case  in  which  the  purging  has  ceased,  when 
the  child  is  in  a  stupor,  or  when  there  is  evidence  of  cerebral  irritation. 
As  soon  as  the  irritability  of  the  stomach  has  been  relieved,  mercury 
with  chalk,  gr.  ss  (0.03),  and  Dover's  powder,  gr.  i-io  (0.006),  or 
bismuth  salicylate  may  be  given,  but  in  many  cases  it  is  better  to 
refrain  from  any  medication.  The  temperature  should  be  reduced  by 
cool  sponging  or  the  graduated  bath.  Ice-water  enemata  or  irrigation 
of  the  large  bowel  reduces  the  temperature  and  relieves  the  thirst.  The 
subcutaneous  injection  of  the  saline  solution,  as  practiced  in  cholera,  is 
often  of  great  benefit  in  replacing  the  water  abstracted  by  the  disease. 
Iced  brandy  or  champagne  in  quantities  of  10  or  15  drops  every  hour 
should  alone  be  given  internally.  If  vomiting  be  persistent,  brandy, 
ether,  or  spirit  of  camphor  may  be  administered  hypodermically.  VATien 
the  surface  of  the  body  is  cold  and  when  the  temperature  is  subnormal, 
warm  mustard-baths  should  be  given,  and  hot-water  bottles  applied 
to  the  extremities.  After  the  severe  symptoms  have  been  allayed,  a 
more  liberal  diet,  beginning  with  albumen-water,  should  be  given,  and 
the  subsequent  management  is  the  same  as  that  of  acute  gastroen- 
teritis. 

ACUTE  ENTEROCOLITIS. 

ACUTE  FOLLICULAR  COLITIS,   FOLLICULAR  DYSENTERY. 

Definition. — An  acute  catarrhal,  often  ulcerative  inflammation  of  the 
ileum  and  colon  of  infants. 

Etiology. — The  disease  occurs  especially  during  the  hot  summer  months 
and  in  the  debilitated  children  of  the  poor.  It  is  peculiarly  troublesome 
in  the  "second  summer"  of  infancy.  All  the  causes  which  lead  to  gastro- 
enteritis and  cholera  infantum  are  operative  in  its  production,  and  it 
is  often  a  sequel  to  one  of  these  diseases  or  of  one  of  the  acute  infections, 
as  diphtheria,  scarlet  fever,  or  measles.  The  resemblance  of  the  disease 
to  acute  dysentery,  and  the  recent  discovery  of  the  bacillus  of  the  latter 
disease  as  a  probable  cause  of  gastroenteritis,  suggest  the  possible  iden- 
tity of  the  two  aff'ections,  except  with  reference  to  the  location  of  their 
lesions. 


SPRUE  OR  PSILOSIS  .  485 

Morbid  Anatomy. — A  catarrhal  inflammation,  with  the  characteristic 
changes  already  described  under  Catarrhal  Enteritis,  is  usually  found 
with  greatest  severity  in  the  colon,  and,  in  addition  to  these,  more  or 
less  extensive  follicular  ulceration. 

Symptoms. — Most  cases  develop  as  attacks  of  acute  gastroenteritis, 
and  gradually  or  suddenly  merge  into  enterocolitis.  The  transition  is 
indicated  by  an  aggravation  of  the  symptoms.  Fever  usually  develops; 
the  stools  become  smaller  and  more  frequent,  and  they  contain  mucus 
and  blood.  Convulsions  sometimes  occur;  and  in  severe  cases  the  dejec- 
tions become  reduced  to  only  blood-stained  mucus,  generally  having  a 
very  oftensive  odor.  Tympanites  and  tenderness,  with  tenesmus  and  the 
passage  of  much  gas,  are  present  in  most  cases.  Death  may  occur 
within  a  few  days  from  toxemia,  with  convulsions  or  coma,  or,  after 
a  week  or  two,  from  exhaustion.  Other  cases  pass  into  a  chronic  con- 
dition, but  final  recover}-  is  the  rule,  except  in  feeble  or  ill-nourished 
children. 

Treatment. — A  few  doses  of  calomel,  gr.  i-io  (0.006),  or  a  purgative 
dose  of  castor  oil  should  be  administered  in  order  to  cleanse  the  upper 
bowel.  The  large  intestine  should  be  irrigated,  once  a  day  or  oftener, 
with  warm  salt  solution  through  a  long  elastic  catheter  introduced  as 
far  as  possible.  The  griping  pains  may  be  relieved  with  warm  appli- 
cations to  the  abdomen,  turpentine  stupes,  hot  fomentations,  or  a  spice 
poultice,  and  the  tenesmus  by  injecting  into  the  rectum  one  or  two 
drops  of  laudanum  in  a  half-ounce  of  starch-water.  The  diet  for  the 
first  day  or  two  should  be  restricted  to  albumen-water  with  a  little 
brandy,  then  to  cream  or  milk  with  lime-water  and  beef-juice.  In  other 
respects  the  treatment  is  that  of  acute  gastroenteritis. 


CELIAC  DISEASE. 

DIARRHEA  ALBA,  DIARRHEA  CHYLOSA. 

This  name  was  applied  by  Gee  to  a  subacute  diarrhea  of  children 
between  one  and  five  years  of  age,  in  which  there  are  large,  frothy, 
pasty,  whitish  stools.  The  cause  is  not  known.  Intestinal  ulceration 
is  sometimes  found.  The  child  becomes  pale  and  emaciated,  the  skin 
dry,  and  the  abdomen  distended,  but  soft.  Fever  is  generally  present, 
but  vomiting  is  unusual.  The  disease  is  very  fatal,  death  occurring  after 
several  weeks,  from  marasmus. 

SPRUE  OR  PSILOSIS. 

This  is  described  by  Manson  as  a  disease  characterized  by  "irregu- 
larly alternating  periods  of  exacerbation  and  of  comparative  quiescence ; 
by  an  inflamed,  bare,  and  eroded  condition  of  the  mucous  membrane 
of  the  tongue  and  mouth ;  by  flatulent  dyspepsia ;  by  pale,  copious,  and 
generally  loose,  frothy,  fermenting  stools ;  by  wasting  and  anemia ;  and 
by  a  tendency  to  relapse.  It  may  occur  primarily  or  it  may  supervene 
on  other  aftections  of  the  bowels."  It  is  of  slow  progress  and  tends 
to  terminate  in  atrophy  of  the  intestinal  mucous  membrane,  that  usually 
proves  fatal.    Musgrave,  on  the  other  hand,  regards  it  as  only  a  second- 


486  PRACTICE  OF  MEDICINE 

Bxy  condition,  which,  Hke  the  typhoid  state,  develops  in  connection 
with  other  diseases,  since  he  failed  in  careful  microscopic  examinations 
to  find  any  additional  etiological  feature  in  any  of  the  cases  observed 
by  him  at  Manila. 

DIPHTHERITIC  ENTERITIS. 

PSEUDOMEMBRANOUS  OR  CROUPOUS  ENTERITIS  OR  COLITIS. 

Definition.— An  inflammation  of  the  small  or  large  intestine  charac- 
terized by  the  formation  of  fibrinous  psuedomembrane  within  or  upon 
the  mucosa. 

Ef/o/ogy.— The  disease  most  frequently  appears  :  (<^)  In  connection 
with  the  acute  infections,  as  typhoid  fever,  pneumonia,  pyemia,  cholera, 
scarlet  fever,  or  tuberculosis;  (^)  as  a  result  of  toxic  influences,  as  from 
lead,  arsenic,  or  mercury;  or  (r)  as  a  terminal  afl"ection  in  chronic 
nephritis,  cancer,  hepatic  cirrhosis,  or  other  cachectic  conditions.  The 
thrush  fungus  has  also  been  met  with  in  the  colon. 

li/lorbid  Anatomy.— The  anatomical  lesions  are  not  uniform  in  char- 
acter. In  some  cases  patches  of  variable  size  and  thickness  are  found 
upon  the  surface  of  the  colon  or  involving  the  entire  thickness  of  its 
mucous  membrane.  It  is  sometimes  confined  to  the  cecum.  The  small  in- 
testine is  generally  markedly  involved  in  toxic  cases.  In  some  instances 
the  membrane  has  a  grayish  white  color  like  that  of  true  diphtheria, 
but  sometimes  it  has  more  the  appearance  of  thick  crusts.  In  yet 
another  group  of  cases  the  disease  affects  especially  the  solitary  folli- 
cles, which  are  enlarged  and  sometimes  suppurating  or  ulcerated  and 
covered  with  the  diphtheritic  formation. 

Symptoms.— The  symptoms  are  those  of  a  more  or  less  severe  entero- 
colitis, with  griping  pain,  frequent  dejections,  prostration,  sometimes 
collapse,  varying  much  with  the  cause  of  the  condition.  In  toxic  cases 
the  stools  are  often  mucopurulent  and  contain  blood.  Tormina  and 
tenesmus  are  frequently  present,  as  in  true  dysentery.  There  are  no 
distinctive  symptoms,  however,  except  the  discharge  of  fragments  of 
the  membrane,  and  the  diagnosis  is  often  impossible  during  life. 

The  treatment  is  symptomatic,  except  so  far  as  it  apphes  to  the 
causative  condition. 

PHLEGMONOUS  ENTERITIS. 

Definition.— A  localized  or  diffuse  suppurative  inflammation  of  the  mu- 
cous membrane  of  the  intestine. 

Etiology.— The  disease  is  extremely  rare  as  a  primary  aff'ection.  It 
is  most  frequently  observed  after  strangulation  or  intussusception,  or 
as  a  result  of  pyemia  or  of  malignant  disease  of  the  bowel.  The  primary 
cases  are  supposed  to  be  due  to  the  presence  of  the  colon  bacillus.  The 
disease  sometimes  accompanies  phlegmonous  gastritis.  The  principal 
symptoms  are  pain,  tympanites,  tenderness,  with  constipation  and  fever. 
Septic  peritonitis,  strongly  suggested  by  these  symptoms,  is  generally 
developed.  The  disease  usually  terminates  fatally  within  a  few  days. 
The  condition  is  seldom  diagnosticated,  but  is  usually  confounded  with 


ULCERATIVE  ENTERITIS  487 

septic  peritonitis  or  one  of  the  conditions  from  which  it  arises.  The 
relief  of  pain,  and  other  measures  for  the  comfort  of  the  patient,  are  the 
only  therapeutic  indications. 

ULCERATIVE  ENTERITIS. 

The  duodenal,  typhoid,  syphilitic,  and  tubercular  ulcers  of  the  intes- 
tine have  already  been  considered.  Several  other  forms  may  be  briefly 
referred  to. 

Simple  Ulcerative  Colitis.— This  affection,  although  of  rather  doubtful 
pathology,  is  worthy  of  study  on  account  of  its  common  confusion  with 
dysentery.  It  is  not  infrequently  encountered  in  men  past  middle  life, 
especially  in  those  who  have  sufi"ered  much  from  digestive  disorders. 
Some  of  the  cases  that  have  been  described  under  this  head,  however, 
were  perhaps  cases  of  either  amebic  dysentery  or  of  phlegmonous  en- 
teritis. The  anatomical  changes  are  not  constant.  In  some  cases  the 
bowel  is  much  dilated  and  the  mucosa  greatly  thickened  and  extensively 
ulcerated;  but  in  others  the  lumen  of  the  bowel  is  diminished.  Polyp- 
oid projections  are  sometimes  seen  on  the  margins  of  the  ulcers.  The 
patient  generally  suffers  from  a  lienteric  diarrhea  or  alternating  con- 
stipation and  diarrhea,  with  frequent  dysenteric  stools,  a  gradual  loss 
of  strength,  and  sallowness  of  the  skin  amounting  to  cachexia.  Per- 
foration of  the  bowel  frequently  occurs,  or  the  condition  may  pass  into 
a  chronic  stage  of  indefinite  duration. 

Follicular  or  Catarrhal  Ulcers.— Sharply  defined  ulcers  limited  to  the 
follicles  of  either  the  small  or  the  large  intestine,  but  particularly  the 
colon,  are  met  with,  especially  in  the  enterocolitis  of  children  or  the 
chronic  dysentery  of  adults.  They  are  sometimes  found  at  autopsy, 
also,  in  connection  with  other  diseases  where  their  presence  had  not  been 
recognized. 

Stercoral  ulcers  are  peculiar  to  cases  of  long-standing  constipation, 
being  formed  in  the  sacculi  of  the  dilated  colon  as  a  result  of  the  pres- 
sure and  irritation  of  the  hardened  fecal  masses,  some  of  which  often 
contain  calcareous  matter. 

Traumatic  ulcers  result  from  the  irritation  caused  by  the  lodgment 
of  foreign  bodies  or  from  the  entrance  of  corrosive  poisons. 

Perforative  ulcers  are  produced  by  the  extension  of  inflammation 
from  without,  as  by  the  pressure  of  a  retroverted  uterus,  new  growths, 
the  rupture  of  an  abscess  or  of  a  gastric  ulcer,  or  from  disease  of  the 
appendix,  pancreas,  or  peritoneum. 

Solitary  ulcer  occasionally  develops  in  the  cecum  or  colon  and  may 
pass  to  perforation.    It  resembles  the  peptic  ulcer  of  the  stomach. 

Amyloid,  scorbutic,  purpuric,  and  leukemic  ulcers  of  the  intestine 
have  been  described  in  connection  with  the  several  diseases  indicated 
by  these  titles. 

Symptoms. — The  symptoms  of  ulcer  of  the  intestine  vary  with  the 
location  and  extent  of  the  ulceration.  Diarrhea  is  a  common  symptom, 
especially  of  ulcers  in  the  colon,  sigmoid  flexure,  or  rectum.  Extensive 
ulceration  may  exist,  particularly  in  the  small  intestine,  without  the 
production  of  diarrhea.  Morning  diarrhea,  often  limited  to  two  passages 
in  close  succession,  is  highly  characteristic  of  rectal  ulcer.    The  passage 


488  PRACTICE  OF  MEDICINE 

of  pus,  shreds  of  tissue,  and  blood,  is  the  distinctive  feature  of  most 
cases;  but  pus  alone  is  not  characteristic,  unless,  perhaps,  in  the  form 
of  small  sago-like  masses  or  plugs  corresponding  in  size  to  the  follicles. 
The  blood  from  an  ulcer  in  the  sigmoid  flexure  or  rectum  may  be  bright 
red  and  fluid,  like  that  from  hemorrhoids,  which  must  be  excluded.  That 
from  the  upper  bowel  is  usually  dark  and  tarry,  and  it  is  sometimes  min- 
gled with  feces.  The  most  profuse  hemorrhage  occurs  as  a  result  of 
typhoid  ulceration  or  the  duodenal  ulcer.  Pain  is  not  common  and  it  is 
not  distinctive,  but  in  some  instances  there  are  localized  pain  and  tender- 
ness directly  over  the  ulcer  and  due  to  peritoneal  inflammation.  Per- 
foration may  occur,  and  it  is  generally  followed  by  a  rapidly  fatal,  sup- 
purative peritonitis.  A  localized  abscess  is  sometimes  produced. 
The  treatment  is  that  of  chronic  catarrhal  enteritis. 

HEMORRHAGE  OF  THE  INTESTINE. 

Intestinal  hemorrhage  is  a  symptom  common  to  a  large  number  of 
conditions.  The  bleeding  may  occur  in  any  part  of  the  intestine,  and 
blood  from  other  sources  not  infrequently  passes  through  the  bowel. 
It  may  thus  originate  in  the  upper  alimentary  or  respiratory  tract 
or  in  the  stomach,  or  it  may  enter  the  intestine  through  the  rupture  of 
an  abscess  or  an  aneurism. 

Etiology. — The  causes  of  true  intestinal  hemorrhage  may  be  general 
or  local  in  character,  i.  The  general  causes  include  such  blood-states 
as  are  ordinarily  accompanied  with  hemorrhage  of  the  mucous  mem- 
branes, as  purpura,  pernicious  anemia,  leukemia,  scurvy,  and  such  pro- 
found intoxications  as  are  seen  in  smallpox,  yellow  fever,  malaria,  and 
bubonic  plague.  It  has  been  noted  also  as  a  rare  form  of  vicarious 
menstruation. 

2.  The  local  causes  are :  (^d)  Hemorrhoids,  probably  the  most  fre- 
quent source  of  hemorrhage  from  the  bowel;  (/^)  anal  fissure  or  fistula 
and  intestinal  polypi;  (^)  all  the  different  forms  of  ulcer  noted  under 
Ulcerative  Enteritis;  (^)  hyperemia,  especially  the  passive  congestion 
from  cirrhosis  of  the  liver  or  valvular  disease  of  the  heart;  (^)  embo- 
lism or  thrombosis  of  the  mesenteric  vessels,  the  result  of  malignant 
endocarditis,  pyemia,  or  other  infection;  C/")  trauma  from  perforating 
wounds,  blows  upon  the  abdomen,  or  the  passage  of  foreign  bodies; 
(<§■)  neoplasms;  (/^)  corrosive  poisons;  (?)  intestinal  parasites,  espe- 
cially the  ankylostomum  duodenale. 

Symptoms. — The  blood  may  be  mingled  with  the  feces  or  it  may  pass 
independently.  As  previously  noted,  it  is  bright  red  and  fluid  when  from 
the  lower  bowel,  but  dark  and  tarry  when  from  a  higher  source,  owing 
to  the  action  upon  it  of  intestinal  juices  and  gases. 

Treatment. — The  treatment  must  be  directed  to  the  cause  of  the 
hemorrhage.  This  will  be  considered  under  the  various  diseased  con- 
ditions that  have  been  named  as  causes. 

HEMORRHAGIC  INFARCTION  OF  THE  INTESTINE. 

This  is  a  rare  condition  usually  caused  by  embolism  of  the  superior 
or  inferior  mesenteric  arteries  or  their  larsrer    branches.      The    remote 


APPENDICITIS  489 

cause  is  generally  a  disease  of  the  heart,  especially  malignant  endocar- 
ditis. The  extent  of  the  infarction  and  the  severity  of  the  consequent 
symptoms  depend  upon  the  size  of  the  vessel  obstructed.  The  wall  of 
the  intestine  becomes  intensely  edematous,  and  the  mucosa  is  covered 
with  blood  and  mucus.  Necrosis  usually  follows,  and  localized  peritonitis 
may  be  developed. 

The  condition  is  manifested  by  the  sudden  development  of  severe 
intestinal  pain,  free  hemorrhage  from  the  bowel,  tympanites,  fall  of  tem- 
perature, and  collapse.  In  some  instances  the  blood  is  retained  in  the 
bowel  and  there  may  be  obstinate  constipation.  The  recognition  of 
the  cardiac  condition  to  which  the  infarction  owes  its  origin  is  generally 
the  key  to  the  diagnosis,  but  the  exclusion  of  hemorrhagic  pancrea- 
titis is  often  extremely  difficult  or  impossible.  The  disease  is  generally, 
if  not  always,  fatal.  The  treatment  is  palliative,  morphin  being  given 
for  the  pain  and  ergot  for  the  hemorrhage.  Cold  applications  may 
afford  relief, 

AMYLOID  DISEASE  OF  THE  INTESTINE. 

Amyloid  degeneration  affects  the  intestine,  along  with  other  structures 
as  a  result  of  prolonged  suppuration,  especially  in  tuberculous  or  syphi- 
litic subjects  and  when  the  suppuration  involves  bone.  Both  the  small 
and  large  intestines  are  generally  involved,  but  the  degeneration  is  most 
pronounced  in  the  lower  ileum  and  upper  colon.  The  process  begins  in 
the  smaller  blood-vessels  and  extends  to  the  mucosa,  which  becomes 
pale  and  thickened.  In  advanced  cases  the  other  layers  of  the  intestine 
may  also  be  involved,  and  ulceration  of  the  mucosa  is  common.  The 
principal  symptom  is  a  profuse  watery  diarrhea,  without  pain.  Hemor- 
rhage of  the  intestine  occasionally  occurs  late  in  the  disease.  The 
recognition  of  the  condition  is  possible,  as  a  rule,  only  through  the  asso- 
ciation of  other  amyloid  disease  and  the  peculiar  waxy  appearance  of 
the  patient,  together  with  the  discovery  of  the  suppurative  focus  back 
of  the  trouble.  Intestinal  amyloid  disease  is  generally  a  late  mani- 
festation and  one  that  signifies  an  early  fatal  termination.  The  treat- 
ment is  purely  symptomatic,  directed  to  the  relief  of  the  diarrhea  or 
hemorrhage  and  the  support  of  the  patient's  strength. 

APPENDICITIS. 

The  appendix  vermiformis  is  an  offshoot  from  the  cecum,  which  ceases  to  undergo  fur- 
ther development  at  an  early  period  of  fetal  life  and  remains  a  "wormlike  process,"  func- 
tionless  so  far  as  we  know.  Its  usual  length  is  about  3  inches  (8  cm.),  but  it  has  been 
found  less  than  i  inch  and  more  than  9  inches  (23  cm.)  in  length.  Its  diameter  is 
«bout  ^4  inch  (0.5  cm.),  but  in  this  also  it  varies.  It  is  provided  with  a  mucous  mem- 
brane rich  in  lymphatic  tissue,  with  numerous  follicles  of  Lieberkuehn.  It  is  partly  sur- 
rounrled  b}'  peritoneum.  On  account  of  its  glandular  structure  it  has  been  called  the 
"abdominal  tonsil"  by  Ransohoff  and  others.  It  has  also  a  mesoappendix,  slightly 
shorter  than  itself  and  bearing  the  same  relation  to  it  as  the  mesocolon  bears  to  the 
colon.  The  distal  end  ma)'  be  found  in  any  position  with  reference  to  the  cecum.  Most 
frequently  it  points  inward  from  the  left  border  of  the  cecum,  crossing  the  psoas  muscle. 
It  is  often  behind  the  cecum  and  may  hang  down  toward  or  into  the  true  pelvis.  The 
lumen  of  the  appendi.x  communicates  with  the  intestine  through  an  orifice  that  is 
sometimes  as  small  as  a  pinhole,  sometimes  large  enough  to  admit  a  No.  7  Englislv 
sound. 


490  PRACTICE  OF  MEDICINE 

Definition. — An  acute  or  chronic  inflammation  of  the  appendix  vermi- 
formis.  The  inflammation  may  be  catarrhal,  ulcerative,  or  sclerotic  in 
character. 

Etiology. — Predisposing  Causes. — The  disease  is  encountered  in  individ- 
uals of  any  age,  but  more  than  half  the  cases  occur  before  the  twenty- 
fifth  year,  and  the  large  majority  of  the  remainder  before  the  fortieth. 
It  is  rare  in  childhood  or  after  the  forty -fifth  year.  The  disease  is  three 
or  four  times  more  frequent  in  males  than  in  females. 

Occupation  and  Habits. — («-)  Individuals  whose  employment  requires 
the  muscular  strain  of  lifting  heavy  weights  appear  more  liable  to  the 
disease  than  others.  QT)  Such  traumatisms  as  blows  or  kicks  in  the 
right  ileac  region  have  repeatedly  preceded  the  illness.  (^)  The  disease 
often  attacks  persons  addicted  to  excessive  eating,  and  more  particularly 
after  such  indiscretion  as  the  insufficient  mastication  of  peanuts  or  the 
swallowing  of  the  pits  of  fruit.  (^)  Constipation  favors  the  disease 
by  permitting  fecal  matter  to  enter  the  appendix  and  there  to  form 
concretions.  These  concretions  often  closely  resemble  the  seeds  of  cher- 
ries, oranges,  dates,  and  other  fruit.  It  is  thought  that  the  concretion 
sometimes  forms  around  a  small  seed  or  a  clump  of  micro-organisms. 
{/)  Indigestible  substances  and  foreign  bodies  passing  through  the  in- 
testine are  especially  liable  to  find  their  way  into  the  appendix.  Such 
bodies  as  spiculae  of  bone,  pins,  seeds,  nuts,  bullets,  and  shot  have 
been  found  in  it.  (/")  Irregularity  in  the  development  of  the  tube,  es- 
pecially an  excess  of  the  glandular  tissue,  is  thought  to  favor  infection. 
(^g)  Twists,  bends,  and  the  pressure  of  neoplasms  or  cicatricial  tissue 
may  act  by  narrowing  the  lumen  and  preventing  normal  drainage.  (Ji) 
Inflammation  is  often  transmitted  to  the  appendix  from  the  colon,  and 
it  may  extend  also  from  surrounding  structures,  as  from  the  right  tube 
in  women.  (/)  The  abdominal  type  of  la  grippe  is  regarded  by  some 
writers  as  a  frequent  cause  of  appendicitis.  The  ulceration  of  typhoid 
fever  occasionally  involves  the  appendix;  cancer  is  sometimes  encoun- 
tered in  it,  and  tuberculosis  is  by  no  means  uncommon.  (/')  Finally, 
one  attack  of  the  disease,  however  mild,  renders  the  individual  liable 
and  almost  certain  to  suffer  from  a  repetition,  the  severity  of  which 
cannot  be  predicted. 

Exciting  Causes. — The  statement  that  bacteria  are  always  the  cause 
of  appendicitis  is  probably  too  radical  except  with  reference  to  the  active 
processes  which  lead  to  suppuration  and  perforation,  for  the  contents  of 
a  cystic  appendix  are  sometimes  sterile.  Among  the  micro-organisms 
which  have  been  found  in  connection  with  the  disease  are  the  strepto- 
coccus pyogenes,  staphylococcus  pyogenes  aureus,  and  the  colon,  pro- 
teus,  pyocyaneus,  typhoid,  and  tubercle  bacilli. 

An  attempt  has  been  made  to  revive  the  old  theory  that  an  attack 
of  appendicitis  may  be  rheumatic  in  nature.  The  theory  is  founded  in 
part  upon  the  resemblance  of  the  appendix  to  the  tonsil,  in  the  abun- 
dance of  its  adenoid  tissue,  and  the  relief  which  sometimes  follows  the 
administration  of  the  salicylates.  But,  until  the  specific  cause  of  rheuma- 
tism has  been  demonstrated,  the  relation  of  the  two  diseases  must  re- 
main theoretical. 

Morbid  Anatomy.— Catarrhal  or  Obliterative  7);/>^.— The  purely  catarrhal 
type,  in  which  the  inflammation  is  limited  to  the  mucous  membrane 


APPENDICITIS  491 

of  the  appendix,  is  little  known  except  by  its  results.  Its  existence  has 
been  sufficiently  established,  however,  as  an  early  stage  of  the  processes 
which  lead  to  more  profound  changes.  In  it  the  mucous  membrane  is 
hyperemic  and  greatly  thickened.  The  surface  epithelium  is  desquamated 
and  the  follicles  of  Lieberkiihn  may  be  entirely  destroyed.  The  entire 
mucous  membrane  is  sometimes  removed,  and  the  inner  surface  is  made 
up  of  granulation  tissue.  If,  through  external  pressure  or  other  means, 
the  surfaces  are  brought  into  contact  while  in  this  condition,  they 
more  or  less  completely  unite.  The  process  then  constitutes  appendicitis 
obliterans.  Its  result  when  complete  is  a  permanent  obliteration  of  the 
lumen  of  the  tube,  and  the  disease  cannot  recur.  In  such  an  appendix 
the  entire  wall  is  generally  found  to  be  thickened  and  the  organ  becomes 
firm  and  stiff  as  rubber  owing  to  the  extensive  hyperplasia  of  the  con- 
nective tissue.  But  complete  obliteration  occurs  in  only  about  2  per 
cent  of  all  cases.  When  it  is  incomplete  the  canal  is  often  closed  at  the 
cecal  end  by  a  constriction,  and  the  appendix  becomes  thickened  to  the 
size  of  the  thumb  or  larger,  constituting  a  cyst,  the  contents  of  which 
may  be  either  a  clear  fluid  or  pus.  Or  the  distention  may  be  due  to 
fecal  concretions,  or  to  mucus  containing  desquamated  epithelium,  leu- 
cocytes, and  mucous-membrane  debris.  The  lumen  is  sometimes  divided 
into  numerous  compartments  through  the  formation  of  cicatricial  bands. 
This  condition  is  always  liable  to  pass  on  to  suppuration  and  perforation. 
In  some  instances,  although  the  distention  is  not  great,  the  obliterative 
adhesions  are  prevented  by  the  rigidity  of  the  thickened  wall.  Repeated 
attacks  of  colic  and  other  manifestations  are  a  common  result.  In 
either  of  these  conditions  the  peritoneal  covering  may  become  involved, 
although  neither  suppuration  nor  perforation  has  occurred.  It  is  then 
covered  with  a  layer  of  fibrin,  and  adhesions  are  generally  formed. 

Ulcei-ative  Type. — Ulceration  may  result  from  the  presence  of  concre- 
tions, foreign  bodies,  or  the  pus-forming  micro-organisms,  and  sometimes 
it  appears  to  be  due  to  the  typhoid  or  tubercle  bacillus.  Actinomy- 
cosis of  the  appendix  has  also  been  described.  An  ulcerative  inflamma- 
tion sometimes  follows  the  catarrhal.  Single  or  multiple  ulcers  may  be 
found,  and  they  may  be  quite  superficial  or  so  deep  as  to  cause  perfo- 
ration. They  may  form  at  any  part  of  the  tube.  As  the  inflammatory 
action  reaches  the  surface,  an  adhesive  peritonitis  is  developed,  uniting 
the  appendix  with  a  loop  of  the  intestine,  the  bladder,  right  kidney, 
ovary,  liver,  abdominal  parietes,  or  any  surface  with  which  it  may  come  in 
contact.  UTien  the  appendix  is  of  unusual  length,  it  may  become  adherent 
to  the  sigmoid  flexure,  the  gall-bladder,  or  other  remote  structiu^e.  But 
although  perforation  may  thus  be  prevented  for  a  time,  a  suppurative 
peritonitis  is  usually  developed.  In  a  large  percentage  of  cases  the 
adhesions  are  incomplete  and  permit  the  escape  of  the  contents  into  the 
peritoneal  cavity,  with  production  of  a  general  peritonitis.  In  some 
instances  a  localized  abscess  is  formed;  its  most  frequent  location  is 
midway  between  the  umbilicus  and  the  anterior  superior  spinous  proc- 
ess. A  common  location  of  smaller  abscesses  is  over  the  psoas  muscle 
at  the  angle  between  the  ileum  and  cecum.  They  may  be  found,  how- 
ever, high  up  in  the  region  of  the  umbilicus,  near  the  promontory  of  the 
sacrum,  or  down  in  the  pelvis.  When  the  perforation  has  occurred 
in  a  part  of  the  appendix  not  covered  with  peritoneum,  an  extraperito- 


492  PRACTICE  OF  MEDICINE 

neal  abscess  is  formed  and  the  peritoneum  may  not  become  affected. 
An  occasional  result  of  the  adhesive  inflammation  is  the  constriction  or 
bending  of  a  loop  of  the  intestine  in  such  a  manner  as  to  produce  tem- 
porary or  permanent  obstruction. 

Necrotic  Type. — This  is  usually  an  advanced  stage  or  consequence  of 
one  of  the  preceding  types.  It  is  perhaps  primary  in  some  instances. 
It  may  affect  the  entire  appendix  or  only  a  limited  portion,  a  single 
small  area  or  several.  Perforation  more  commonly  follows  the  limited 
necrosis.  In  either  case,  a  severe  localized  or  general  peritonitis  is  the 
usual  result.  The  localized  gangrene  with  consequent  perforation  is 
more  frequently  found  at  the  base,  close  to-  the  cecum,  but  it  may  occur 
at  the  tip  or  at  any  point  in  the  wall.  The  appendix  often  sloughs  oft", 
and  is  then  found  as  a  highly  necrotic  mass  in  the  abscess  cavity.  When 
still  adherent  it  may  be  dark  red,  black,  or  greenish,  corresponding  to 
the  degree  of  necrosis.  In  all  cases  of  this  type,  micro-organisms  are 
found  in  great  numbers  in  the  extremely  fetid  pus.  It  is  more  probable 
that  the  pus-forming  streptococci  and  staphylococci  are  the  active  agents, 
particularly  the  streptococci  in  the  more  virulent  cases,  but  in  a  large 
number  of  cases  the  Bacillus  coli  communis  has  been  the  only  organism 
found.  This  fact  has  been  explained  by  Welch,  however,  as  due  to  the 
ability  of  this  bacillus  to  outlive  the  other  organisms  in  the  presence 
of  inflammation. 

Remote  Effects  of  Perforation. — These  are  due,  for  the  most  part,  to  ab- 
scess-formation or  the  burrowing  of  pus  and  its  erosive  action.  When 
the  perforation  is  extraperitoneal,  a  retroperitoneal  abscess  is  formed. 
The  pus  may  pass  beneath  the  iliac  fascia  and  even  perforate  the  skin 
in  the  region  of  Poupart's  ligament,  or  it  may  pass  beneath  the  liga- 
ment. It  sometimes  travels  along  the  psoas  muscle,  and  may  reach  the 
hip  joint,  the  scrotum,  or,  by  passing  through  the  obturator  foramen, 
form  as  abscess  in  the  gluteal  region.  It  sometimes  burrows  upward 
to  form  a  perinephric  abscess,  or  still  further  to  erode  the  liver  or  per- 
forate the  peritoneum  in  this  region.  It  has  also  passed  through  the 
diaphragm  and  pleura  into  the  lung.  More  common  avenues  of  perfo- 
ration, especially  for  the  intraperitoneal  abscesses,  is  into  some  portion 
of  the  intestine,  the  urinary  or  gall-bladder,  vagina,  or  rectum;  and  in 
a  few  instances  the  pus  has  penetrated  a  hernial  sac  or  found  an  external 
exit  through  the  abdominal  wall. 

An  occasional  result  of  perforation  is  the  erosion  of  a  blood-vessel, 
with  severe  or  fatal  hemorrhage.  The  internal  iliac  artery,  portal  vein, 
and  smaller  vessels  in  the  walls  of  the  intestines  or  other  viscera  have 
been  perforated.  Phlebitis  of  the  mesenteric  vein  and  abscess  of  the  liver 
are  occasional  results. 

Symptoms. — There  is  scarcely  another  disease  in  which  the  symptoms 
are  so  diverse  or  in  which  they  may  be  so  little  significant  of  the  real 
pathological  condition  as  this.  It  is  better,  therefore,  not  to  attempt 
a  classification  of  them  into  types,  but  to  study  the  disease  in  its  en- 
tirety, for  the  mildest  onset  often  precedes  a  rapidly  fatal  course,  and  the 
severest  cases  may  subside  with  surprising  rapidity.  In  some  cases 
symptoms  are  absent,  or  they  are  so  mild  as  to  attract  little  attention. 
Many  cases  begin  gradually  with  manifestations  which  may  be  regarded 
as  prodromal.    These  are  generally  characterized  by  colicky  pains  and 


APPENDICITIS  493 

tenderness  more  or  less  confined  to  the  right  ihac  fossa,  with  malaise, 
loss  of  appetite,  constipation  or  diarrhea,  sometimes  also  with  nausea 
and  vomiting.  With  or  without  these  early  manifestations,  however, 
there  is  ordinarily  a  sudden  paroxysm  of  severe  pain.  This  is  followed 
with  fever,  gastrointestinal  disturbances  (constipation,  nausea,  and 
vomiting),  and  tenderness  or  pain  on  pressure  over  the  region  of  the  ap- 
pendix. 

Pain. — The  pain  is  usually  violent  and  begins  suddenly,  without  obvi- 
ous cause,  or  it  may  follow  one  of  the  recognized  causes  of  the  disease, 
an  error  in  diet,  a  blow,  strain,  or  jar.  It  may  amount  only  to  a  sense 
of  discomfort,  but  it  is  often  sharp  and  agonizing.  It  is  generally  per- 
sistent, but  subject  to  paroxysmal  exacerbations.  It  is  often  referred 
at  first  to  the  umbilical,  epigastric,  or  hypogastric  region,  or  it  may  be 
diffused  over  the  abdomen,  but  it  becomes  localized  in  most  cases  within 
twenty-four  to  forty-eight  hours,  in  the  right  iliac  fossa.  Extremely 
sharp  pain  usually  denotes  an  involvement  of  the  peritoneum  with  great 
danger  of  perforation,  or  that  this  has  already  occurred.  On  the  other 
hand,  no  positive  deduction  can  be  made  from  the  character  of  the  pain, 
for,  although  severe,  it  is  sometimes  transitory,  and  sometimes,  it  is 
thought,  significant  only  of  appendicular  colic,  occasioned  by  violent 
peristaltic  action  in  attempts  to  expel  mucus  from  the  interior  of  the 
appendix. 

Fever. — Elevation  of  temperature  is  one  of  the  most  significant  symp- 
toms, since  it  indicates  an  inflammatory  process  as  the  source  of  the 
pain.  It  not  only  serves  to  exclude  appendicular  colic,  an  afebrile  con- 
dition, but  it  is  highly  indicative  of  the  severity  of  the  inflammation 
or  the  presence  of  suppuration.  It  usually  develops  within  twenty-four 
hours  after  the  onset;  it  may  be  preceded  by  chilly  sensations,  but  sel- 
dom by  a  distinct  rigor.  In  a  mild  case  it  may  never  exceed  ioi°  F. 
(38,5°  C),  except  in  children,  when  it  is  usually  higher.  In  severe  cases 
it  frequently  rises  rapidly  to  103°  or  104°  F.  (39.5° — 40°  C.)-  It  gener- 
ally pursues  an  irregular  course.  But  fever  fails  to  prove  a  trustworthy 
sign  in  many  cases  and  can  never  be  implicitly  relied  upon,  for  even 
in  the  presence  of  abscess  it  may  be  absent,  and  in  some  of  the  severest 
cases,  when  general  peritonitis  is  present  from  the  beginning,  the  tem- 
perature is  subnormal.  The  pulse  is  usually  accelerated  in  ratio  to 
the  temperature.  The  respiration  is  often  superficial  or  irregular  on 
account  of  the  pain. 

Gastrointestinal  Disturbances. -^T\\q  tongue  is  coated,  though  usually 
moist.  The  appetite  is  lost,  and  thirst  is  generally  excessive.  Nausea 
and  vomiting  are  more  uniformly  present  in  severe  perforative  cases; 
they  may  be  absent  in  the  milder  types.  Obstinate  constipation  is  the 
rule  after  the  onset.  Hiccough  is  often  an  annoying  symptom.  Great 
irritability  of  the  bladder  is  often  complained  of.  The  urine  is  scant, 
often  albuminous,  and  indican  is  generally  present. 

Physical  Examination. — Inspection. — The  facial  expression,  general  con- 
dition and  attitude,  of  the  patient  are  of  much  value  in  arriving  at  a 
diagnosis.  As  the  Hippocratic  or  abdominal  fascies  indicates  extensive 
involvement  of  the  peritoneum,  so  its  absence  may  signify  the  reverse. 
In  cases  having  a  mild  beginning,  the  patient  may  continue  at  his 
vocation  for  a  day  or  two,  but  in  walking  he  assumes  a  shght  stoop 


494  PRACTICE  OF  MEDICINE 

and  leans  to  the  right.  In  most  instances,  however,  he  at  once  takes 
to  his  bed.  Here  he  hes  on  his  back  or  possibly  on  the  right  side,  with 
the  right  knee  drawn  up.  There  is  usually  nothing  peculiar  in  the  ap- 
pearance of  the  abdomen  unless  the  disease  has  progressed  unfavorably 
for  a  few  days.  After  abscess-formation  or  perforation  it  becomes  dis- 
tended, and  the  right  side  may  be  sHghtly  the  more  prominent. 

Three  valuable  signs  are  elicited  by  palpation  and  percussion,  namely, 
rigidity,  tenderness,  and  dullness. 

Rigidity. — Abnormal  resistance  to  pressure  over  the  right  iliac  fossa 
is  usually  an  early  sign.  It  is  due  chiefly  to  rigidit}-  of  the  right  rectus 
muscle,  which  is  unmistakable  when  compared  with  the  normal  tension 
of  the  left.  In  from  twenty-four  to  forty-eight  hours,  sometimes  earlier, 
a  distinct  swelling  can  often  be  felt  in  the  region  of  the  cecum.  It  is 
sometimes  concealed,  however,  by  the  abdominal  rigidity  or  by  the  dis- 
tention of  the  intestine,  unless  the  patient  be  anesthetized. 

Tetiderness.—T\\^^x^  is  usually  from  the  beginning  great  tenderness  or 
acute  pain  on  pressure  in  the  right  ihac  fossa.  In  a  majority  of  cases 
the  most  acutely  sensitive  spot  is  found  at  "  McBurney's  point."  This 
is  situated  on  a  line  drawn  from  the  umbilicus  to  the  right  anterior 
superior  spinous  process,  where  it  intersects  the  outer  margin  of  the  right 
rectus  muscle.  The  pressure  should  be  made  with  the  tip  of  one  finger 
pressed  deeply  and  firmly  into  the  abdominal  wall.  In  some  cases, 
owing,  perhaps,  to  an  unusual  position  of  the  appendix,  the  greatest 
tenderness  may  be  found  in  another  location,  or  it  may  be  diff'used 
over  a  wider  area.  Rectal  or  vaginal  palpation  is  sometimes  of  value 
in  such  cases,  for  a  characteristic  point  of  tenderness,  the  swollen  appen- 
dix, or  more  certainly  an  abscess  of  large  size,  may  be  felt.  Fluctua- 
tion can  sometimes  be  obtained  by  palpation  of  an  abscess  of  considera- 
ble size. 

Dullness.— ?txz\x%%\OTv  elicits  a  dull  tympanitic  note  over  the  region 
when  there  is  tumefaction  of  considerable  extent. 

While  all  these  signs  are  of  value  when  well  marked,  the  absence  of 
any  one  or  more  of  them  does  not  preclude  the  presence  of  appendiceal 
disease.  They  are  often  less  distinctly  recognizable  or  altogether  ab- 
sent after  perforation  has  occurred,  although  there  may  be  extensive 
burrowing  of  pus, 

Blood-Count.— L^ViQ.ocyto%\?>  is  usually  present,  especially  after  suppu- 
ration has  occurred,  when  it  may  exceed  50,000. 

Cot/rse.— Mild  cases,  in  which  pus  is  absent  or  so  small  in  quantity 
that  it  can  be  absorbed,  usually  ameliorate  after  three  or  four  days. 
The  pain  subsides,  the  fever  declines,  the  constipation  yields;  all  the 
symptoms  abate,  and  recovery  is  complete  in  from  ten  to  twenty  days. 
Sometimes  the  recovery  is  less  rapid,  and  slight  fever  persists  during  a 
week  or  two.  Recovery  occurs,  however,  in  a  majority  of  all  cases.  It 
is  sometimes  permanent,  but  too  often  it  is  of  only  short  duration. 
Recurrence  is  to  be  anticipated,  particularly  in  cases  in  which  induration 
or  tumefaction  remains  in  the  region  of  the  appendix. 

Chronic  Appendicitis.— This  term  is  sometimes  given  to  cases  in  which 
the  induration  fails  to  subside  with  the  other  symptoms.  The  patient 
usually  suff'ers  from  a  more  or  less  constant  uneasiness  in  the  ileac  re- 
gion, or  occasional  attacks  of  pain,  with  or  without  other  symptoms. 


APPENDICITIS  495 

Recurrent  Appendicitis. — In  another  large  class  of  cases  an  apparently- 
complete  recovery  takes  place  and  the  induration  subsides,  but  in  the 
course  of  three  or  four  months,  often  much  earlier,  a  relapse  occurs, 
accompanied  with  all  the  symptoms  of  the  original  attack.  This  may 
also  be  recovered  from,  and  another  relapse  may  follow,  and  thus  the 
disease  may  run  on  for  several  years.  Ultimate  recovery  sometimes 
occurs  in  these  cases,  probably  as  a  result  of  obliterative  inflammation 
or  from  the  evacuation  of  a  pus  cavity  into  the  bowel,  but  any  of  the 
attacks  may  prove  fatal,  and  the  condition  is  an  exceedingly  dangerous 
one. 

Cases  that  are  characterized  by  a  sudden,  violent  onset  usually  cor- 
respond to  the  suppurative  or  ulcerative  type  of  the  disease.  The  ini- 
tial symptoms  in  many  cases  do  not  correspond  to  the  actual  beginning 
of  the  disease.  The  inflammatory  process  may  have  been  going  on 
for  an  indefinite  time,  and  the  sudden  pain,  tenderness,  and  fever  indicate 
the  beginning  of  suppuration,  the  rupture  of  the  distended  appendix, 
or  possibly  the  giving  way  of  an  abscess  that  has  formed  insidiously. 
Although  the  symptoms  may  ameliorate  after  three  or  four  days,  as  in 
a  mild  case,  the  improvement  is  generally  of  short  duration.  The  fever, 
as  a  rule,  assumes  a  remittent  course  from  the  beginning,  and  after  a  few 
days  the  symptoms  of  sepsis  become  clearly  marked.  Death  may  result 
from  septicemia,  pyemia,  or  pyelophlebitis,  without  rupture  of  the  appen- 
dix, but  it  is  more  frequently  a  result  of  general  peritonitis,  which  may 
be  produced  through  the  action  of  bacteria,  either  before  or  after  rup- 
ture. 

Peritonitis,  as  just  stated,  may  result  from  infection  without  rupture 
of  the  appendix,  but  it  is  more  commonly  a  result  of  that  accident. 
The  pus  is  sometimes  shut  off"  from  the  general  peritoneum  by  adhesions, 
producing  a  localized  abscess.  The  abscess  may  rupture  later  and  set 
up  a  general  peritonitis.  In  many  instances  the  general  peritoneal  in- 
volvement has  been  established  before  the  appearance  of  acute  symptoms, 
and  herein  lies  the  greatest  danger  of  the  disease.  The  initial  sudden, 
sharp  pain  often  means  the  onset  of  peritonitis  and  the  termination  of 
a  previously  unrecognized  appendicitis.  It  is  then  usually  followed  within 
a  few  hours  by  an  extension  of  the  pain  and  tenderness  more  or  less 
generally  over  the  abdomen,  with  distention,  tympanites,  and  rigidity 
of  both  sides.  The  pulse  becomes  rapid  and  feeble,  the  respiration  cor- 
respondingly fast,  often  irregular  or  stertorous,  the  voice  weak,  and  the 
face  anxious  and  pinched.  The  tongue  is  dry  and  the  bowels  are  con- 
stipated and  vomiting  persistent,  while  the  urine  becomes  scant  or  sup- 
pressed. The  temperature  is  variable,  sometimes  not  over  ioo°  F. 
(37-5°  C.),  sometimes  over  105°  F.  (40.5°  C).    Death  is  inevitable. 

Diagnosis.— K  sudden  attack  of  violent  pain  in  the  right  iliac  fossa, 
in  a  person  who  was  previously  healthy,  especially  in  one  under  30  years 
of  age,  and  yet  more  positively  if  associated  with  abdominal  rigidity, 
tenderness  on  pressure  in  this  region,  vomiting,  constipation  or  diarrhea, 
is  almost  invariably  due  to  appendicitis,  for  this  is  the  most  common 
of  all  inflammatory  diseases  of  the  abdomen  in  early  life.  The  diag- 
nosis becomes  difficult  only  when  some  of  the  symptoms  are  absent 
or  when  unusual  manifestations  appear,  as  when  the  pain  is  referred  tct 
a  distant  region.     The  greatest  cause  of  error  is,  no  doubt,  too  great 


496  PRACTICE  OF  MEDICINE 

haste  in  reaching  a  conclusion.  To  avoid  this,  the  complete  history  of 
the  case  should  be  carefully  obtained  and  carefully  studied ;  then  a  thor- 
ough examination  should  be  made  with  a  view  to  excluding  all  possible 
sources  of  error.    Many  affections  enter  into  the  consideration. 

1.  Colic. — Severe  intestinal  colic  may  for  a  time  cause  confusion, 
but  the  absence  of  distinctive  signs  in  the  appendix  region  is  generally 
sufficient.  Diarrhea  is  more  common  than  constipation.  In  hepatic 
colic  the  conditions  usually  found  in  the  right  iliac  fossa  are  absent; 
the  pain  generally  radiates  toward  the  right  shoulder  and  back ;  the  ten- 
derness is  confined  to  the  region  of  the  liver  and  gall-bladder  if  calculi 
are  present,  and  jaundice  commonly  appears.  Gall-stones  may  be  found 
in  the  feces.  Renal  colic  is  excluded  by  careful  palpation  of  the  abdomen 
and  examination  of  the  urine.  Pain  radiating  to  the  bladder  and  penis 
or  scrotum  is  more  common  than  in  appendicitis,  and  gravel  is  fre- 
quently passed.  Dietl's  crises,  due  to  movable  kidney,  are  relieved  by 
restoration  of  the  organ  to  its  proper  position.  Gastrointestinal  dis 
turbances  are  less  common.  Lead  colic  is  less  likely  to  be  mistaken 
for  appendicitis  than  the  reverse,  for  without  careful  examination  the 
pain  of  the  latter  condition  may  be  referred  to  lead  colic  when  it  occurs 
in  a  subject  of  lead-intoxication. 

2.  Perforation  of  Ulcers. — The  symptoms  arising  from  the  perforation 
of  gastric,  duodenal,  or  typhoid  ulcer  may  be  mistaken  for  appendicitis, 
but  can  usually  be  excluded  by  the  history  of  the  case  and  the  absence 
of  the  local  signs  of  the  latter  disease. 

3.  Intestinal  obstruction,  intussusception,  fecal  impaction,  internal 
strangulation,  and  other  obstructive  conditions  can  generally  be  ex- 
cluded, but  not  always  without  difficulty.  Fecal  impaction  of  the  cecum 
is  of  slower  onset,  the  pain  is  moderate  at  first  and  of  a  colicky  char- 
acter, the  tumor  is  usually  large  and  hard,  sometimes  doughy,  and 
there  is  less  tenderness ;  the  right  rectus  is  not  generally  so  tense.  Bloody 
mucous  evacuations  usually  accompany  intussusception.  Fecal  vomiting 
is  common  to  nearly  all  obstructions.  The  tympanites  develop  rapidly 
and  may  be  confined  to  the  upper  part  of  the  abdomen.  Pericecal 
abscess  cannot  be  differentiated  from  that  due  to  appendicitis  without 
incision,  but  the  differentiation  is  unimportant,  since  both  conditions  call 
for  operative  treatment. 

4.  Psoas  Abscess.— F\u.ctVia.t\on  can  be  more  uniformly  obtained,  and 
examination  of  the  spine  reveals  the  source  of  the  pus  in  most  cases. 

5.  Renal  Disease.— The  pain  of  pyonephrosis,  perinephritic  abscess, 
or  tumor  of  the  right  kidney  is  often  excluded  with  difficulty.  Exami- 
nation of  the  urine  may  reveal  the  condition,  but  in  perinephric  abscess 
the  differentiation  cannot  be  made  without  exploratory  incision. 

6.  Hemorrhagic  pancreatitis  may  be  mistaken  for  appendicitis,  in  part 
on  account  of  its  rarity,  but  the  pain  is  usually  different  in  character 
and  location. 

7.  Female  Disorders.— T\\e  colicky  pain  of  the  menstrual  period  is 
sometimes  a  source  of  error.  A  neuralgia  of  the  right  ovary  is  more 
likely  to  cause  difficulty  in  diagnosis.  In  both  conditions,  however, 
the  absence  of  tumefaction  or  rigidity  of  the  rectus,  with  the  history  of 
the  case  before  the  attack  and  during  the  few  days  succeeding  it,  gener- 
ally reveals  the  true  condition.    Pyosalpinx,  pelvic  hematocele,  and  pelvic 


APPENDICITIS  497 

peritonitis  can  generally  be  recognized  on  careful  examination,  but  the 
differentiation  from  a  ruptured  appendix  is  extremely  difficult  except 
Avith  a  clear  history  of  the  case.  Extrauterine  pregnancy  may  rarely 
be  a  source  of  confusion.  The  signs  of  pregnancy  are  usually  to  be 
found  in  the  breast;  and  the  location  of  the  tumor,  pain,  and  tenderness, 
seldom  corresponds  to  that  of  the  appendix. 

8.  Typhoid  fever  does  not  occasion  confusion  when  the  history  of 
the  case  is  obtained.  The  iliac  pain  is  seldom  so  severe  at  an  early 
period  of  the  disease;  the  tumor  is  not  present;  the  rectus  muscle  is 
not  so  rigid,  and  the  fever  is  higher  and  more  regular  in  its  course. 
The  presence  of  leucocytosis  speaks  for  appendicitis,  the  Widal  reaction 
for  typhoid  fever. 

9.  Enteralgia,  mucous  colitis,  and  other  painful  affections  occurring 
in  neurasthenic,  h_ysterical,  or  hypochondriacal  persons  often  closely 
simulate  appendicitis  on  account  of  the  strong  conviction  in  the  mind 
of  the  patient  that  the  disease  is  present.  In  an  individual  who  is  fa- 
miliar with  the  symptoms  of  the  disease  the  picture  may  be  so  accu- 
rately drawn  that  unless  the  most  careful  physical  examination  be  made 
without  regard  to  the  subjective  manifestations,  the  most  skillful  diag- 
nostician may  be  misled. 

Prognosis. — A  large  majority,  estimated  at  80  to  90  per  cent  of  all 
cases,  recover  spontaneously  or  under  treatment.  Nevertheless,  a  favor- 
able prognosis  should  not  be  too  -early  pronounced,  for  the  most  favor- 
able condition  may  be  converted  into  the  most  unfavorable  within  a 
very  few  hours.  The  outlook  becomes  less  hopeful,  as  a  rule,  with  each 
succeeding  attack  of  the  disease,  not  only  because  each  attack  brings 
the  patient  into  greater  danger  of  perforation,  but  because  a  condition 
is  ultimately  reached  which  is  exceedingly  unpropitious  for  operative 
measures.  No  deduction  can  be  safely  drawn  from  the  experience  of 
the  patient,  the  physician,  or,  indeed,  from  medical  and  surgical  statis- 
tics. Every  case  has  peculiarities  of  its  own  and  it  must  be  regarded  as 
fully  liable  to  the  most  unfavorable  results.  We  have  no  means  of  recog- 
nizing the  obliterative  appendicitis,  although  it  may  be  assumed  to  have 
been  present  when  the  disease  finally  ceases  spontaneously  after  a  series 
of  attacks. 

Treatment — The  patient  should.be  strictly  confined  to  bed  and  made 
as  comfortable  as  possible.  For  the  relief  of  the  pain  an  ice-bag  should 
be  placed  over  the  region  of  the  appendix.  Opium  should  be  avoided 
if  possible,  for  it  often  masks  the  real  condition,  but  in  extreme  cases 
morphin  must  be  given  hypodermically  in  doses  only  sufficient  to  render 
the  suftering  bearable.  Full  doses  of  sodium  salicylate  often  afford 
relief  without  producing  profound  insensibility  to  pain  and  tenderness. 
Relief  sometimes  follows  a  copious  enema  of  warm  soap-suds,  but  the 
internal  administration  of  laxatives  is  objected  to  by  most  authors. 
The  diet  should  be  exclusively  liquid. 

The  most  important  question  to  be  determined  is  the  advisability 
of  resorting  to  surgical  measures.  It  is  only  in  a  case  that  runs  a  mild 
course  from  the  start,  and  shows  distinct  improvement  bv  the  third  or 
fourth  day,  that  this  question  can  be  decided  in  the  negative.  The  neces- 
sity of  an  operation  should  be  urged  upon  the  patient:  i.  If  he  has 
passed  through  one  or  two  previous  attacks;  2,  in  every  case  of  severe 

32 


498  PRACTICE  OF  MEDICINE 

onset  with  violent  pains;  3,  in  every  case  in  which  a  tumor  can  be  rec- 
ognized; 4,  whenever  a  mild  case  shows  a  sudden  increase  of  severity, 
with  rise  of  temperature,  severe  pain,  or  the  development  of  a  tumor ; 
5,  in  every  case  in  which  there  is  evidence  that  suppuration  or  perfora- 
tion has  occurred,  providing  that  the  patient's  condition  admits  of  im- 
mediate operation.  In  all  cases  of  uncertainty,  the  surgeon  should  be 
called  without  avoidable  delay,  and,  when  the  indications  are  distinct, 
the  operation  should  be  performed  without  the  delay  of  an  hour,  for  the 
mortality  after  early  operation  is  inconsiderable,  and  the  chances  of 
recovery  rapidly  diminish  with  each  day  of  procrastination. 

INTESTINAL  OBSTRUCTION. 

ILEUS,   OBSTIPATION. 

1.  Strangulation  (Constriction  of  the  Bowel,  Intra-Abdominal  Her- 
nia).— The  exhaustive  investigations  of  intestinal  obstruction  by  Fitz 
have  given  us  the  best  analysis  of  the  condition.  Strangulation  consti- 
tutes about  35  per  cent  of  all  cases  of  obstruction.  It  may  be  partial 
or  complete.  It  is  much  more  frequent  in  males,  and  nearly  half  the 
cases  occur  between  the  ages  of  15  and  30.  The  small  intestine  is  in- 
volved in  nearly  90  per  cent  of  cases  and  usually  in  the  lower  part  of 
the  abdomen;  often  in  the  right  iliac  fossa  (67  per  cent). 

Etiology. — The  causes  in  the  order  of  their  frequency  are :  bands, 
cords,  slits,  and  fissures  in  the  omentum  and  mesentery,  diaphragmatic 
hernia,  and  peritoneal  pouches.  Rare  forms  of  strangulation  are  the 
duodenojejunal  hernia  of  Treitz,  in  which  a  loop  of  the  intestine  slips 
into  the  duodenojejunal  fossa ;  and  the  hernia  of  the  omental  bursa,  in 
which  the  loop  passes  through  the  foramen  of  Winslow.  The  condition 
producing  the  strangulation,  unless  a  congenital  defect,  is  generally  a 
consequence  of  previous  peritonitis.  This  is  particularly  the  cause  of  the 
formation  of  adhesive  bands  between  the  intestine  and  the  abdominal 
wall,  as  after  a  surgical  operation,  between  loops  of  intestine  or  between 
persistent  vitelline  remains,  as  a  prolongation  of  Meckel's  diverticulum 
or  obliterated  vitelline  blood-vessels  and  other  abdominal  viscera.  In 
the  same  manner  the  tip  of  the  vermiform  appendix  may  become  at- 
tached and  cause  constriction  of  a  coil  of  the  intestine,  which  slips 
through  the  unnatural  opening. 

2.  Intussusception  (Invagination).— In  this  condition,  which  consti- 
tutes over  30  per  cent  of  the  cases  of  obstruction,  a  constricted  portion 
of  the  intestine  is  forced  into  a  relaxed  portion  immediately  below  it. 
Nothnagel  believes  that  the  lower  bowel  is  drawn  up  over  the  constricted 
upper  portion.  It  is  a  condition  peculiar  to  early  life,  a  majority  of 
cases  occurring  in  males  before  the  tenth  year  and  fully  one-third  in  the 
first  year. 

Eiiology.—ln  a  majority  of  cases  diarrhea  or  habitual  constipation 
precedes  the  invagination,  but  in  some  cases  no  more  definite  cause  can 
be  assigned  than  irregular  or  excessive  peristaltic  action.  An  invagina- 
tion sometimes  occurs  at  the  time  of  death,  but  it  can  be  distinguished  at 
autopsy  by  the  absence  of  adhesions  or  other  evidence  of  inflammation. 

Morbid  Anatomy.— Ks  a  result  of  intussusception,  a  cylindrical  tumor 


INTESTINAL  OBSTRUCTION  499 

is  produced,  which  varies  in  length  from  a  few  inches  to  a  foot  or  more. 
In  extreme  cases  the  ileocecal  valve  has  been  found  in  the  rectum.  The 
intussusception  consists  of  three  layers  of  intestine.  The  outer,  known 
as  the  intussuscipiens,  or  receiving  layer,  is  continuous  with  the  bowel 
below,  and  the  innermost,  or  entering  layer,  with  the  bowel  above.  The 
middle  or  returning  layer  joins  the  two.  The  mesentery  attached  to  the 
entering  layer  is  also  drawn  in,  and  as  a  result  the  opening  at  the  lower 
extremity  of  the  invaginated  part  has  the  appearance  of  a  slit.  The 
invaginated  portion  has  a  dark  red  or  purplish  color  due  to  congestion, 
and  the  veins  are  distended  with  blood.  Hemorrhages  are  commonly 
found  within  or  upon  the  walls.  The  peritoneal  surfaces  of  the  entering 
and  returning  layer,  lying  in  contact  with  each  other,  show  the  changes 
of  acute  peritonitis,  being  covered  with  fibrin  and  more  or  less  firmly 
united  by  adhesions.  In  some  cases  the  invaginated  portion  becomes 
separated  and  is  discharged  as  a  slough.  Union  may  then  take  place 
between  the  upper  and  lower  portion  of  the  bowel  at  the  mouth  of  the 
invagination.  Fibrous  stricture  is  apt  to  form,  but  complete  recovery 
has  occurred  in  many  cases. 

3.  Twists  (Volvulus)  and  Knots.— These  constitute  14  per  cent  of  all 
cases.  A  majority  (68  per  cent)  of  twists  are  encountered  in  men,  and 
about  one-third  of  them  between  the  ages  of  30  and  40.  The  large  in- 
testine is  involved  in  nearly  90  per  cent  of  cases,  most  commonly  the 
sigmoid  flexure,  next  the  cecum.  The  condition  is  favored  by  an  unusual 
length  of  the  mesentery,  elongation  of  the  intestine  by  hernia,  the  trac- 
tion of  adhesions,  or  an  accumulation  of  feces.  Rarely  a  loop  of  the 
intestine  is  twisted  about  another  portion.  The  bowel  may  be  twisted 
on  its  long  axis  a  half-turn,  a  whole  turn,  or  more,  complete  strangula- 
tion being  produced.  The  intestine  below  the  constriction  is  distended 
and  deeply  congested.  A  fatal  peritonitis  is  usually  developed.  Knots 
are  extremely  rare. 

4.  Stricture  and  Tumors. — Stricture  of  the  intestine  sometimes  exists 
at  birth,  or  more  commonly  the  canal  is  completely  obliterated  in  a 
part  of  its  length,  as  is  usually  the  case  in  imperforate  anus  or  when 
the  duodenum  is  separated  from  the  stomach.  Acquired  strictures  are 
generally  a  result  of  the  cicatricial  healing  of  ulcers.  These  may  be 
stercoral,  syphilitic,  or  tubercular,  or  they  may  result  from  a  localized 
peritonitis,  the  repair  of  an  intussusception,  or  very  rarely  from  dysen- 
tery or  typhoid  fever.  Tumors  cause  obstruction  either  through  oblit- 
erating the  lumen  of  the  intestine  when  within  it,  or  by  compressing  or 
drawing  upon  the  bowel  from  without.  Cancer  is  the  most  frequent 
cause,  and  it  is  generally  located  in  the  large  bowel,  very  often  in  the 
sigmoid  flexure  or  rectum.  It  is  more  common  in  women  after  the  for- 
tieth year.  Papilloma,  fibroma,  adenoma,  and  lipoma  occasionally  cause 
occlusion.  Pelvic  abscess  may  compress  the  bowel.  An  accumulation  of 
feces  in  one  portion  of  the  bowel,  as  in  the  sigmoid  flexure,  sometimes 
closes  an  adjacent  loop  of  the  intestine  by  compression. 

5.  Abnormal  Contents.— The  most  common  cause  of  obstruction  by 
foreign  bodies  is  an  accumulation  of  gall-stones,  A  majority  of  the 
patients  are  women,  all  are  adults,  and  six-sevenths  are  over  50.  The 
next  most  common  cause  is  impaction  of  feces.  This  may  occur  in  either 
sex  and  at  any  period  of  hfe,  often  in  young  children.    Enteroliths  not 


500  PRACTICE  OF  MEDICINE 

infrequently  occur.  These  generally  have  as  a  nucleus  some  undigested 
substance,  as  hair,  thread,  fragments  of  bone,  or  the  pits  or  husks  of 
fruit,  and  an  external  coating  of  calcium  or  magnesium  phosphate.  They 
are  often  as  large  as  a  hen's  egg.  Foreign  bodies  of  every  description 
may  be  swallowed  and  pass  to  the  intestine,  or  they  may  be  introduced 
into  the  rectum  and  produce  obstruction.  The  most  common  of  these 
are  coins,  nails,  stones,  pins,  buttons,  and  artificial  teeth ;  but  spoons, 
forks,  arid  other  large  articles  have  been  found. 

Symptoms. — ((^)  Acute  Obstruction. — The  usual  symptoms  of  acute 
obstruction  are  constipation,  abdominal  pain,  tympanites,  and  tumor. 
At  the  beginning  of  the  obstruction,  several  loose  dejections  often  occur, 
but  a  complete  stoppage  follows,  often  so  complete  that  neither  fluid 
nor  gas  can  pass  it.  Pain  in  the  abdomen  is  an  early  symptom  and 
often  develops  suddenly.  It  is  at  first  colicky,  but  soon  becomes  intense 
and  continuous.  In  intussusception  the  pain  is  more  gradual  in  onset 
and  it  may  have  the  character  of  tenesmus.  Localized  tenderness  may 
be  present,  but  it  is  not  characteristic.  Vomiting  is  a  constant  symptom 
and  it  generally  follows  immediately  after  the  initial  pain.  It  may  be 
preceded  by  eructations  of  gas.  The  contents  of  the  stomach  are  first 
brought  up,  then  a  greenish,  bile-stained  fluid,  and  finally,  by  the  third 
day,  a  feculent,  brownish  liquid  (stercoraceous  vomiting).  The  solid 
contents  of  the  large  intestine  are  probably  never  carried  up,  but  the 
fluid  contents  may  pass  the  ileocecal  valve  and  appear  in  the  vomit. 
There  are  frequent  efforts  at  the  evacuation  of  the  bowel,  with  the  dis- 
charge of  only  a  little  blood-stained  mucus.  Tympanites  and  abdominal 
distention  become  extreme  when  the  large  bowel  is  obstructed.  They  are 
less  pronounced  in  intussusception  or  when  the  obstruction  affects  the 
upper  part  of  the  small  intestine.  A  palpable  tumor  is  more  character- 
istic of  intussusception  than  of  other  forms  of  obstruction.  The  tumor 
may  be  felt  in  the  rectum  or  through  the  abdominal  wall,  often  in  both 
locations,  and,  as  a  rule,  during  the  first  two  or  three  days  of  the  ob- 
struction. It  has  the  form  of  an  elongated  cylinder  or  sausage-like 
mass.  When  it  reaches  the  rectum,  a  peculiar  relaxation  of  the  anus  is 
often  observed. 

Constitutional  symptoms  are  generally  well  marked.  There  may  be 
slight  fever  after  the  first  day  of  strangulation,  but  collapse  is  common, 
and  the  temperature  may  then  be  subnormal.  When  peritonitis  develops, 
the  temperature  generally  rises,  the  pulse  becomes  rapid  and  feeble,  there 
is  incessant  thirst,  and  the  tongue  becomes  parched.  The  urine  is  of 
high  color  and  scant  when  vomiting  is  excessive;  it  may  be  suppressed 
when  the  obstruction  is  in  the  upper  bowel. ,  It  often  contains  albumin 
and  indican.     Hiccough  is  sometimes  a  troublesome  symptom. 

(<^)  Chro7iic  Obstruction. — Constipation  of  long  duration  is  a  constant 
symptom  in  this  condition.  When  the  obstruction  is  due  to  fecal  ac- 
cumulation, the  dejections  usually  become  less  and  less  frequent  for  a 
period  of  several  weeks,  possibly  for  months.  The  obstructing  mass  is 
sometimes  channeled  in  such  a  manner  as  to  permit  a  part  of  the  con- 
tents of  the  bowel  above  to  pass  through,  and  the  patient  may  thus  have 
evacuations  at  regular  intervals.  The  bowel  may  become  extensively 
eroded  or  ulcerated,  and  a  fatal  perforation  or  peritonitis  may  occur 
without  complete  obstruction.     Sometimes  an  evacuation  does  not  occur 


INTESTINAL  OBSTRUCTION  501 

once  in  a  week,  especially  in  old  persons,  and  yet  little  discomfort  is  ex- 
perienced. There  may  be  frequent  mucous  discharges  and  attacks  of 
nausea  and  vomiting.  Finally  the  abdomen  becomes  much  distended  and 
severe  pain  develops.  Feculent  vomiting  ensues  as  the  obstruction  be- 
comes complete.  The  hardened  mass  of  feces  may  be  felt  through  the 
rectum  or  abdominal  wall  as  a  large,  slightly  movable  tumor.  \^^en  the 
obstruction  is  due  to  stricture  or  tumor,  the  pain  corresponds  to  the 
location  of  the  obstruction.  Anemia  and  emaciation  are  common.  The 
case  generally  terminates  fatally  with  the  symptoms  of  acute  obstruc- 
tion, but  of  more  than  the  usual  duration.  Death  may,  however,  result 
from  exhaustion,  without  complete  arrest  of  alvine  evacuations. 

Diagnosis. — An  early  diagnosis  of  the  condition  is  important.  It  is 
necessary  to  take  into  consideration  the  situation  of  the  obstruction,  its 
nature,  and  the  exclusion  of  other  conditions  which  lead  to  error.  The 
situation  of  obstruction  is  revealed,  as  a  rule,  by  the  history  of  the  case, 
inspection  and  palpation  of  the  abdomen,  and  examination  of  the  rectum. 
Inspection  may  reveal  the  part  obstructed  through  the  character  of  the 
distention  and  the  location  of  peristaltic  movements  when  visible.  When 
the  obstruction  is  low  in  the  large  bowel,  the  colon  may  stand  out  prom- 
inently and  a  tumor  may  sometimes  be  felt,  but  the  entire  abdomen  is 
often  distended.  Feculent  vomiting  is  absent,  at  least  until  late.  With 
the  obstruction  in  the  region  of  the  ileocecal  valve,  the  distention  is 
greatest  in  the  umbilical  region,  as  a  rule,  and  the  feculent  vomiting  ap- 
pears early.  The  folds  of  the  small  intestine  may  be  thrown  into  ladder- 
like prominences  by  the  increased  peristalsis.  When  the  duodenum  or 
jejunum  is  obstructed,  the  distention  is  usually  confined  to  the  upper 
part  of  the  abdomen,  the  urine  is  suppressed,  fecal  vomiting  does  not 
occur,  but  collapse  develops  early.  In  obstruction  involving  the  large 
bowel,  digital  examination  of  the  rectum  may  reveal  it.  Examination 
through  the  vagina  is  often  useful.  When  these  methods  fail,  the  bowel 
should  be  distended  with  warm  water,  with  the  aid  of  an  anesthetic  if 
necessary,  the  patient  lying  on  his  back  or  right  side  with  the  hips  well 
elevated.  The  water  should  be  allowed  to  flow  in  slowly,  especially  after 
the  first  or  second  day,  from  a  fountain  syringe  at  a  height  of  not  more 
than  three  feet,  for  the  bowel  may  be  ruptured  by  too  great  pressure. 
The  quantity  of  fluid  that  can  be  introduced  sometimes  reveals  the  situa- 
tion of  the  obstruction.  The  adult  colon  should  hold  six  quarts,  the 
rectum  three  pints.  The  capacity  of  the  infant  colon  is  about  three 
pints.  Inflation  with  air  is  sometimes  practiced,  but  it  is  a  less  satisfac- 
tory method. 

The  nature  of  the  obstruction  is  usually  more  difficult  to  determine 
than  its  location.  The  statistics  already  given  are  of  much  service  in 
this  respect.  The  character  and  location  of  the  pain  and  the  presence  or 
absence  of  fever  are  of  little  diagnostic  importance.  A  majority  of  cases 
are  due  to  strangulation  or  intussusception.  The  former  is  a  condition 
of  adult  life,  the  latter  of  childhood.  In  strangulation  the  history  is 
important  with  reference  to  former  attacks  of  peritonitis  or  a  laparot- 
omy; a  tumor  is  seldoni  present.  Intussusception  is  characterized  par- 
ticularly by  tenesmus  and  frequent  small,  bloody,  mucous  dejections. 
The  sausage-shaped  tumor  is  usually  felt  in  the  region  of  the  trans- 
verse colon.    Acute  obstruction  of  the  large  intestine  is  generally  due  to 


502 


PRACTICE  OF  MEDICINE 


intussusception,  volvulus,  a  tumor,  or  stricture.  The  first  of  these  is 
practically  eliminated  after  childhood.  Volvulus  can  seldom  be  diagnosti- 
cated, but  its  frequent  location  at  the  sigmoid  flexure  should  be  remem- 
bered. Tumors  may  be  recognized  by  rectal  examination  or  abdominal 
palpation.  Stricture  is  of  slow  formation,  giving  a  history  of  increasing 
constipation  for  a  week  or  more.  Impaction  of  feces  is  more  common  in 
old  persons,  and  the  mass  can  be  felt  in  the  rectum  or  along  the  course 
of  the  colon.  Its  shape  can  generally  be  altered  by  external  pressure. 
Obstruction  by  gall-stones  is  usually  indicated  by  a  history  of  repeated 
attacks  of  gall-stone  colic.  Vomiting  occurs  early  and  jaundice  is  some- 
times observed. 

Hernia. — Careful  examination  should  always  be  made  to  exclude  pos- 
sible hernial  strangulation,  even  when  no  external  signs  exist. 

Appendicitis  sometimes  simulates  obstruction,  but  it  is  generally  recog- 
nized by  the  intense  localized  pain  and  tenderness,  with  fever. 

Peritonitis  is  characterized  by  great  abdominal  tenderness,  an  eleva- 
tion of  temperature,  but  tumor  and  feculent  vomiting  are  absent. 

Blows  on  the  abdomen  and  prolonged  laparotomy  are  sometimes  fol- 
lowed by  obstinate  constipation,  but  the  other  symptoms  of  obstruction 
are  absent  and  the  history  of  the  case  explains  it. 

Persistent  constipatio7i  occurring  in  connection  with  floating  kidney, 
renal  or  hepatic  colic,  and  other  conditions,  especially  when  tympanites 
also  develops,  may  arouse  suspicion  of  obstruction,  but  the  history  of 
the  case,  the  character  of  the  abdominal  distention,  the  absence  of  tumor, 
and  the  action  of  large  enemata  usually  remove  all  uncertainty. 

Prognosis. — This  depends  largely  upon  the  character  of  the  obstruc- 
tion and  the  promptness  of  the  treatment.  Obstruction  from  strangula- 
tion is  usually  fatal  unless  an  early  resort  to  surgery  is  had.  Relief 
sometimes  occurs  spontaneously  or  follows  treatment.  Intussusception 
generally  proves  fatal  from  the  third  to  the  fifth  day,  but  recovery  is 
sometimes  secured.  Obstruction  by  gall-stones  or  fecal  accumulation  is 
much  less  fatal. 

Treatment. — General. — Purgatives  must  never  be  administered.  The 
vomiting  and  pain  may  be  greatly  relieved  by  lavage  of  the  stomach. 
When  the  suffering  is  intense,  however,  morphin  should  not  be  withheld, 
although  it  is  claimed  that  it  obscures  the  diagnosis.  It  sometimes 
renders  a  thorough  examination  less  difficult,  because  less  painful.  The 
tympanites  may  be  reduced  by  turpentine  stupes.  All  food  should  be 
withheld,  except  as  it  can  be  administered  by  the  rectum. 

Special  Treatment. — The  treatment  of  nearly  all  cases  of  acute  ob- 
struction is  surgical,  but,  to  be  of  benefit,  the  operation  must  be  made 
within  the  first  three  days,  on  the  first  or  second  day  if  possible.  When 
the  diagnosis  cannot  be  determined  so  early,  an  exploratory  incision  is 
generally  indicated.  Intussusception  can  sometimes  be  overcome  on  the 
first  day  without  operation,  through  the  injection  of  a  large  quantity  of 
water  or  olive  oil.  The  patient  should  be  anesthetized,  and  his  body 
held  in  an  inverted  position.  The  colon  is  then  filled,  and  the  reduction 
of  the  invagination  may  be  assisted  by  kneading  the  abdomen  or  by 
shaking  the  patient  violently.  The  method  may  be  repeated  if  necessary, 
but  after  the  first  day  it  is  not  devoid  of  danger,  and  the  case  should  be 
submitted  to  the  surgeon. 


CONSTIPATION  503 

Chro7iic  obstruction,  before  it  has  become  complete,  may  be  treated 
by  irrigation  and  the  administration  of  the  mildest  laxatives.  When  it 
has  become  complete,  it  should  be  treated  as  an  acute  case,  and  an 
operation  may  be  required.  Enterectomy  or  the  establishment  of  an 
artificial  anus  may  be  found  necessary. 

CONSTIPATION. 

COSTIVENESS. 

Definition. — Prolonged  retention  of  feces,  or  the  habitually  difficult  or 
infrequent  evacuation  of  the  bowels. 

Etiology. — In  many  cases  there  appears  to  be  a  constitutional  prone- 
ness  to  constipation,  and  an  entire  family  is  often  thus  affected.  It  is 
probably  a  result  of  a  similarity  in  habits  of  life  and  disregard  of  hy- 
gienic and  dietetic  rules  acquired  in  childhood,  and  not  a  result  of  heredi- 
tary influences. 

Age  and  Sex. — Constipation  may  occur  at  any  age,  but  it  is  especially 
frequent  after  middle  life,  when  the  vital  functions  become  sluggish  and 
muscular  exercise  is  neglected.  It  is  not  uncommon  in  infants,  even  from 
birth.  Women  are  much  more  subject  to  it  than  men,  probably  to  a 
great  extent  on  account  of  the  greater  capacity  of  the  pelvis,  which 
permits  distention  of  the  rectum  without  discomfort.  It  is  often  caused 
by  retroversion  of  the  uterus  and  tumors  within  the  pelvis.  Repeated 
pregnancy  and  the  menopause  favor  its  development. 

Habits. — Sedentary  habits  and  mental  application  induce  constipation 
largely  through  inducing  neglect  of  the  natural  calls  for  evacuation. 
Neglect  of  physical  exercise  removes  one  of  the  influences  which  maintain 
the  flow  of  bile  and  increase  the  peristaltic  movements  of  the  intestine. 
Railroad  travel  often  induces  constipation. 

Diseases. — Any  condition  of  ill  health  is  liable  to  produce  constipation. 
It  is  generally  associated  with  anemia,  often  with  neurasthenia,  hysteria 
(nervous  constipation),  chronic  disease  of  the  heart,  stomach,  intestines, 
or  liver.  Stricture  of  the  esophagus  or  at  the  pylorus  induces  it  by  pre- 
venting the  passage  of  the  food  into  the  intestines.  Central  nervous  and 
mental  diseases,  especially  insanity,  chronic  myelitis,  and  destructive 
lesions  of  the  cord,  are  commonly  attended  with  obstinate  constipation. 
The  condition  prevails  in  the  acute  fevers,  except  those  which  affect  di- 
rectly the  intestinal  tract,  as  cholera  and  typhoid  fever. 

Diet  is  one  of  the  most  important  factors.  Food  which  leaves  too 
little  or  too  much  residue,  improperly  prepared  or  insufficiently  masti- 
cated food,  particular  articles,  as  cheese,  nuts,  raw  vegetables,  and  cer- 
tain beverages,  as  milk,  tea,  and  some  of  the  sour  wines,  induce  constipa- 
tion to  a  greater  extent  in  some  individuals  than  in  others.  The  drinking 
of  an  insufficient  quantity  of  water  is  a  common  cause.  The  loss  of 
fluid  by  profuse  sweating  in  hot  weather,  and  lactation,  are  regarded  as 
influential  in  many  cases.    Diabetics  are  usually  constipated. 

Symptoms.— Const\\)a.t\on  often  exists  for  a  long  time  without  produc- 
ing other  abnormal  manifestations  than  the  condition  itself,  but  sooner 
or  later  in  most  cases  definite  symptoms  arise.  These  have  been  attrib- 
uted by  some  writers  to  copremia,  the  absorption  of  poisonous   matter 


504  PRACTICE  OF  MEDICINE 

from  the  retained  feces.  Different  individuals  are  affected  quite  differently. 
Some  experience  much  discomfort  from  constipation  of  a  day's  duration, 
while  others  are  not  at  all  inconvenienced  by  retention  for  a  week,  and 
complain  of  illness  only  on  the  days  on  which  the  bowels  move.  The 
most  constant  symptoms  are  headache,  lassitude,  physical  and  mental 
debility,  and  inaptitude  for  work.  Hypochondriasis,  hysteria,  melan- 
cholia, seminal  emissions,  enuresis  of  children,  and  many  other  disorders 
have  been  attributed  to  constipation.  The  appetite  is  generally  lost,  the 
tongue  becomes  heavily  coated,  the  breath  foul,  and  the  patient  suffers 
from  a  sense  of  abdominal  weight  and  distention.  Periodic  attacks  of 
slight  fever  are  not  uncommon.  Neuralgia  is  often  complained  of,  espe- 
cially that  of  the  sacral  nerves  due  to  the  pressure  of  the  fecal  accumu- 
lation in  the  sigmoid  flexure.  In  women  the  distention  of  the  rectum  is 
often  a  cause  of  painful  menstruation.  Hemorrhoids  are  often  induced 
by  the  pressure  of  the  hemorrhoidal  veins;  ulcers,  by  the  pressure  and 
infection  of  the  intestinal  mucosa;  and  fissures,  by  the  passage  of  the 
hardened  masses.  Attacks  of  cramps  and  abdominal  distention  usually 
occur  at  variable  intervals,  and  diarrhea  not  infrequently  alternates 
with  the  constipation,  especially  when  a  hardened  fecal  accumulation 
becomes  channeled  in  such  a  manner  as  to  permit  the  escape  of  the 
contents  of  the  upper  bowel.  The  patient  often  acquires  a  sallow,  muddy 
complexion,  and  acne  or  eczematous  eruptions  may  appear. 

Constipation  in  infants  is  often  due  to  improper  food,  milk  that  is  too 
rich  in  casein  or  deficient  in  fat.  Failure  to  give  the  infant  an  occa- 
sional drink  of  water  is  a  common  cause  of  it.  Sometimes,  no  doubt,  it 
is  a  result  of  feeble  digestive  power.  It  has  been  caused  in  some  in- 
stances by  congenital  stricture,  a  constricting  band  or  other  structural 
defects.  The  condition  is  common  and  often  very  difficult  of  relief  The 
principal  symptoms  are  colic,'  abdominal  distention,  and  sometimes 
vomiting. 

Prognosis.— T\A%  depends  chiefly  upon  the  cause  and  duration  of  the 
afi"ection  and  the  physical  condition  of  the  patient.  Serious  results  are 
generally  due  to  gross  neglect  on  the  part  of  the  patient.  Constipation 
of  infants  usually  disappears  immediately  upon  the  commencement  of  a 
mixed  diet. 

Treatmeni. — General. — Constipation  seldom  develops  in  those  who 
have  acquired  the  habit  of  evacuating  the  bowels  at  a  fixed  hour  every 
day.  The  importance  of  this  habit  is  not  sufficiently  recognized.  And 
there  is  no  more  important  measure  for  the  cure  of  constipation.  The 
patient  should  retire  to  the  closet  at  a  stated  time,  even  when  there  is 
no  desire.  He  should  sit  and  wait,  without  straining,  for  probably  ten 
minutes.  If  a  spontaneous  movement  does  not  then  occur,  an  enema  of 
cold  water,  a  weak  salt  solution,  or  soap-suds  may  be  employed.  Gly- 
cerin, 3  j  in  a  pint  of  water  or  in  a  suppository,  is  more  active.  Individ- 
uals of  sedentary  habits  should  resort  to  systematic  exercise,  walking  in 
the  open  air,  or  moderate  horseback  or  bicycle  riding.  Those  with 
pendulous  or  relaxed  abdomens  should  wear  an  abdominal  band,  and 
practice  calisthenics  with  especial  reference  to  the  strengthening  of  the 
abdominal  muscles,  swinging  the  arms  upward  and  bending  to  touch  the 
floor.  If  a  gymnasium  is  accessible,  they  should  use  the  overhead  pulleys 
and  the  pumping  apparatus.    Massage  of  the  abdomen  is  useful  in  most 


HEMORRHOIDS  505 

cases,  and  the  "cannon-ball,"  weighing  5  or  6  pounds,  may  be  rolled  over 
the  abdomen,  following  the  course  of  the  colon. 

Dietetic— The  diet  must  be  regulated  to  suit  the  individual  case. 
Persons  whose  food  has  been  too  coarse  should  modify  it  so  as  to  avoid 
such  articles.  In  many  persons  coarse  food,  as  Graham  or  brown  bread 
and  oatmeal,  act  as  laxatives.  Fruit,  especially  an  orange  or  an  apple 
before  breakfast,  and  such  vegetables  as  lettuce,  spinach,  onions,  and  to- 
matoes are  beneficial  in  many  cases.  Salads  containing  much  oil  are 
wholesome.  Molasses  and  honey  are  laxative,  and  some  persons  can 
regulate  the  bowels  by  eating  a  piece  of  taffy  every  day.  An  important 
element  of  treatment  in  some  cases  is  the  regulating  of  the  time  of  meals 
and  the  taking  of  sufficient  time  for  thorough  mastication  of  the  food. 
The  patient  should  learn  to  drink  plenty  of  water.  A  glass  of  cold  water 
immediately  before  retiring  and  on  rising  in  the  morning  is  often  bene- 
ficial. Hot  water  is  more  serviceable  in  some  cases  if  taken  morning  and 
evening  or  before  each  meal.  Strong  coffee,  beer,  cider,  and  carbonated 
waters  are  laxative  to  some  persons. 

■Medicinal. — Drugs  should  be  avoided  if  possible.  When  they  are 
deemed  necessary,  a  small  dose  of  a  saline  laxative,  sodium  or  magne- 
sium sulphate  or  sodium  phosphate,  should  be  given  in  the  morning  be- 
fore breakfast,  or  the  fluid  extract  of  cascara  sagrada,  3  ss  to  j  (1.8—3.6), 
or  the  compound  licorice  powder,  3  j  (^z-^^  ^  at  night.  The  3-grain  cascara 
pill  is  usually  preferred  to  the  bitter  fluid  extract.  Many  other  drugs, 
singly  or  combined,  especially  aloes,  colocynth,  rhubarb,  and  podophyllin, 
are  employed,  and  the  addition  of  the  extract  of  belladonna,  gr.  1-12 
(0.005),  and  nux  vomica,  gr.  14;  (0.016),  to  the  prescription  is  recom- 
mended. 

Constipation  in  infants  can  often  be  overcome  by  giving  an  occasional 
drink  of  water,  allowing  the  infant  to  suck  a  few  drams  from  a  linen 
rag,  by  administering  two  or  three  drams  of  cream  in  water  before  each 
nursing  time,  or  by  adding  it  to  the  artificial  food.  Barley-water  or 
oatmeal-water  acts  well  in  some  cases.  A  small  glycerin  or  soap  sup- 
pository is  generally  efficient  for  moving  the  bowels,  or  a  small  injection 
of  cold  water  may  be  employed.  For  older  children  the  effervescent 
magnesium  citrate  solution  is  generally  agreeable,  but  there  is  no  better 
laxative  than  castor  oil.  Children  old  enough  to  eat  fruit  seldom  require 
drugs. 

HEMORRHOIDS. 

PILES,   EMERODS. 

Definition.— A.  varicose  condition  of  the  external  hemorrhoidal  veins, 
producing  painful  swellings  just  within  or  around  the  external  margin  of 
the  anus.  When  the  swelling  affects  the  veins  beneath  the  mucous  mem- 
brane within  the  external  sphincter,  the  protrusions  are  known  as  inter- 
nal hemorrhoids ;  when  those  beneath  the  skin,  they  are  external  hemor- 
rhoids. 

£f/o/o5'/.— Hemorrhoids  occur  most  frequently  in  middle  and  advanced 
life;  they  are  rare  before  puberty.  Both  sexes  are  affected,  but  men 
more  frequently  than  women.  The  common  cause  is  venous  stasis.  This 
may  be  due  to  a  local  condition,  especially  to  the  pressure  of  accumu- 


5o6  PRACTICE  OF  MEDICINE 

lated  feces  in  habitual  constipation,  to  stricture  of  the  rectum,  to  tumors 
of  the  rectum,  prostate,  uterus,  or  ovaries,  or  to  more  remote  obstruc- 
tion as  that  of  the  portal  vein  in  cirrhosis  of  the  liver,  or  general  venous 
stasis  in  the  chronic  dilatation  of  valvular  disease  of  the  heart.  Preg- 
nancy often  induces  them.  Excessive  indulgence  in  alcohol,  and,  more 
remotely,  all  the  influences  which  lead  to  constipation,  favor  the  develop- 
ment of  hemorrhoids. 

Symptoms. — These  vary  with  the  character  and  severity  of  the  disease. 
Internal  piles  often  exist  without  causing  inconvenience  and  may  not  be 
recognized  until  an  erosion  and  bleeding  occur  in  the  passage  of  a  hard- 
ened mass.  In  many  cases,  however,  the  hemorrhoidal  mass  is  extruded 
with  every  act  of  defecation.  Free  bleeding  often  occurs,  and  this,  in 
severe  cases,  produces  anemia.  Rarely,  hemorrhage  takes  place  indepen- 
dently of  defecation.  A  considerable  quantity  of  blood  may  be  lost  ex- 
ternally, or  it  may  be  retained  within  the  rectum  and  discharged  with  the 
stool  without  the  patient's  knowledge.  Such  cases  may  be  recognized 
only  in  a  search  for  the  cause  of  an  obscure  anemia.  As  a  rule,  how- 
ever, only  a  small  quantity  of  blood  is  lost,  perhaps  only  enough  to 
streak  the  fecal  mass  as  it  passes.  A  sense  of  fullness,  itching,  burning, 
or  pain  often  accompanies  severe  cases,  especially  during  and  after  defeca- 
tion. In  the  worst  cases  the  pain  may  be  reflected  to  the  loins  or  it 
may  radiate  down  the  thighs  and  legs  to  the  soles  of  the  feet.  In  cases 
of  long  standing  an  anesthetic  condition  of  the  anus  is  sometimes  pro- 
duced which  renders  the  patient  unable  to  recognize  the  completion  of 
defecation,  or  there  may  be  a  constant  desire  for  evacuation.  Vesical 
irritation  is  sometimes  an  aggravating  symptom.  Constipation  is  usu- 
ally kept  up  through  the  patient's  dread  of  defecation.  No  little  distress 
is  often  occasioned  by  the  inability  to  retain  the  hemorrhoidal  mass 
within  the  sphincter ;  the  slightest  exertion,  even  walking,  a  cough,  or  a 
sneeze,  will  sometimes  cause  it  to  protrude  and  possibly  to  bleed.  Vari- 
ous reflex  symptoms,  as  hypochondriasis  and  melancholia,  are  more  or 
less  directly  a  result  of  the  condition  in  some  cases. 

External  hemorrhoids  cause  inconvenience  more  than  suffering,  except 
when  they  become  eroded  through  friction. 

Prognosis. — Serious  results  are  seldom  produced,  but  when  the  condi- 
tion is  attended  with  profuse  hemorrhage,  the  patient's  health  may  be 
greatly  impaired  and  a  coexistent  disease  may  be  aggravated. 

Treatment.— Tht  curative  treatment  of  internal  hemorrhoids  is  surgi- 
cal, and  every  case  should  be  submitted  to  the  surgeon  unless  the  condi- 
tion of  the  patient  precludes  the  administration  of  an  anesthetic.  Such 
cases  are  often  encountered  by  the  physician.  The  indications  are,  to 
overcome  the  constipation  and  to  relieve  symptoms  as  they  arise.  Relief 
of  the  irritation  is  generally  afforded  by  suppositories  containing  opium 
extract  and  powdered  nutgalls  with  iodoform  or  ichthyol.  A  condition 
of  comfort  almost  amounting  to  cure  may  then  be  obtained  from  the 
habitual  use  of  an  enema  of  cold  water,  or  very  hot  water  immediately 
before  defecation.  This  should  be  done  at  a  fixed  hour  every  day.  The 
best  time  in  many  cases  is  just  before  retiring,  since  protrusion  of  the 
hemorrhoids  may  otherwise  follow.  The  quantity  of  water  should  not 
exceed  a  pint,  as  a  rule;  just  enough  to  relieve  venous  engorgement  and 
stimulate  peristalsis.    It  should  not  flow  from  a  height  of  more  than 


DILATATION  OF  THE  COLON  507 

three  feet,  for  rectal  dilatation  may  be  induced  by  too  large  a  quantity 
or  too  great  pressure.  The  patient  must  sometimes  be  taught  to  reduce 
the  protrusion.  This  is  generally  done  without  difficulty,  after  bathing 
it  with  cold  water,  by  pressing  it  upward  with  the  fingers  while  making 
an  expulsive  effort.  When,  however,  the  piles  become  strangulated, 
cocain  or  general  anesthesia  is  sometimes  necessary  if  permissible.  Ex- 
ternal piles  are  often  cured  by  an  ointment  of  gallic  acid,  gr.  x  in  an 
ounce  of  vaselin.    Incision  and  evacuation  of  the  clot  are  better. 

ENTEROPTOSIS. 

GLENARD'S  DISEASE. 

Deffnition. — An  abnormal  descent  of  the  intestines  in  the  abdominal 
cavity,  usually  associated  with  prolapse  of  the  other  viscera  (visceropto- 
sis). The  terms  used  to  describe  the  descent  of  the  individual  organs 
are :  Gastroptosis,  descent  of  the  stomach ;  splenoptosis,  descent  of  the 
spleen;  coloptosis,  descent  of  the  colon.  Displacement  of  the  liver  is 
very  rare. 

Etiology. — The  condition  may  be  due  to  congenital  laxity  of  mes- 
enteric attachment,  but  it  is  more  common  in  young  women,  especially 
in  anemic  neurasthenics;  and  in  another  class  of  cases,  it  is  due  to  a 
removal  of  the  support  of  the  abdominal  wall  as  a  result  of  constipa- 
tion, pregnancy,  ascites,  or  ovarian  cyst. 

Symptoms. — In  some  cases  there  is  little  or  no  disturbance,  while  in 
others  the  patient  experiences  a  constant  abdominal  discomfort.  Con- 
stipation and  digestive  disorders  are  present,  and  these  may  lead  to 
emaciation,  debility,  and  melancholia.  The  transverse  colon  can  some- 
times be  felt  just  above  the  pelvis,  and  the  acute  bending  of  it  may 
occasion  more  or  less  complete  obstruction.  Its  location  can  readily  be 
determined  by  artificial  inflation. 

Treatment. — This  is  directed  to  (i)  the  relief  of  constipation,  (2) 
support  of  the  abdomen  by  a  properly  adjusted  abdominal  bandage, 
and  (3)  the  general  condition  of  the  patient,  particularly  the  relief  of 
the  neurasthenic  state.  When  the  abdominal  walls  are  much  relaxed, 
massage  and  calisthenics  are  advantageous. 

DILATATION  OF  THE  COLON. 

Etiology. — The  causes  are  (i)  increased  pressure,  distention,  from 
within  the  bowel,  (2)  diminished  resistance  on  the  part  of  the  intestinal 
walls,  and  (3)  obstruction.  Congenital  dilatation  is  also  recognized 
(Hirschsprung's  disease). 

1.  The  increased  pressure  from  within  may  be  produced  by  either 
gaseous  or  solid  contents.  The  dilatation  is  at  first  temporary,  but, 
often  repeated,  it  leads  to  permanent  enlargement. 

2.  The  diminished  resistance  on  the  part  of  the  abdominal  wall  may 
result  from  (^)  the  acute  distention,  (/-)  a  paretic  condition  of  the 
muscular  coat  which  may  have  originated  in  a  general  enfeeblement  of 
the  system  through  anemia  and  malnutrition,  or  (<:)  a  prolonged  use  of 
cathartics. 


5o8  PRACTICE  OF  MEDICINE 

3.  Obstruction  is  generally  due  to  Qa^  congenital  narrowing  of  the 
lumen,  (Z^)  acquired  stricture,  (r)  foreign  bodies,  (^)  impaction  of  feces 
or  gall-stones,  (,?)  incomplete  twist,  especially  at  the  sigmoid  flexure,  or 
(/")  pressure  from  without,  by  tumors  or  displaced  organs. 

Morbid  Anatomy. — The  colon  is  sometimes  enormously  dilated  and  its 
wall  may  be  extremely  thin.  In  less  pronounced  cases,  the  walls  may 
appear  normal  or  the  muscular  layer  may  be  hypertrophied.  In  the 
case  of  the  "balloon  man"  recorded  by  Formad,  the  colon  was  from  15 
to  30  inches  in  circumference  and  with  its  contents  weighed  47  pounds. 

Symptoms. — These  are  more  prominent  when  the  dilatation  is  acute; 
when  the  dilatation  is  gradual,  it  may  occasion  comparatively  little 
discomfort.  In  a  severe  case  cardiac  palpitation  and  dyspnea  or  fatal 
embarrassment  of  the  heart  and  lungs  may  result  from  the  upward 
pressure.  Obstinate  constipation  is  the  rule,  and  in  cases  caused  by 
obstruction  frequent  spells  of  vomiting  occur.  Percussion  reveals  an  in- 
creased area  of  colon  tympanites,  particularly  after  artificial  distention. 

Diagnosis. — This  is  determined  by  the  history  of  the  case  and  a  careful 
examination  as  to  the  cause  of  the  abdominal  distention.  The  condition 
is  to  be  differentiated,  as  a  rule,  from  gaseous  distention  of  the  peritoneal 
cavity  due  to  perforation  of  typhoid,  gastric,  or  other  ulcers.  Such 
perforation,  however,  is  announced  by  sudden  acute  pain  and  collapse. 
The  tympanites  extends  over  the  area  of  normal  hepatic  dullness.  Perito- 
nitis is  quickly  developed,  with  elevation  of  temperature  and  diffuse 
tenderness. 

Treatment. — i.  Acute  gaseous  distention  can  often  be  relieved  by  the 
passage  of  the  rectal  tube,  giving  vent  to  the  gas.  Turpentine  stupes 
are  beneficial.  2.  When  due  to  fecal  accumulation,  enemata  containing 
ox-gall,  and  restriction  of  diet,  especially  the  exclusion  of  starchy  food, 
may  overcome  the  condition.  Laxatives  should  be  regularly  adminis- 
tered, and  antifermentatives,  salol,  bismuth  subgallate,  or  betanaphthol, 
may  prevent  a  recurrence.  3.  When  anemia  and  malnutrition  are  pres- 
ent, the  administration  of  iron  and  strychnin  is  indicated,  and  abdominal 
massage  may  prove  beneficial.  4.  Cases  due  to  obstruction  often  require 
surgical  treatment — the  making  of  an  artificial  anus  or  excision  of  a 
portion  of  the  bowel. 

NEUROSES  OF  THE  INTESTINE. 

NERVOUS  DIARRHEA. 

Definition. — A  functional  motor  disturbance  of  the  intestine,  producing 
diarrhea. 

Etiology. — The  condition  is  encountered  in  either  sex  and  at  any  age, 
but  it  is  more  common  in  nervous  or  hysterical  women  at  the  menopause 
or  in  connection  with  disease  of  the  generative  organs.  It  is  not  infre- 
quent, however,  in  young  women.  Anemia,  malnutrition,  and  disordered 
gastric  digestion  are  predisposing  causes.  Back  of  the  disorder  there  is 
very  frequently  a  strong  emotion,  as  of  grief,  hope,  or  fear.  Disappoint- 
ment, bereavement,  fright,  anger,  and  pain  induce  acute  attacks,  which 
may  prove  persistent.  The  aftection  is  sometimes  observed  in  connection 
with  nervous  affections,  as  exophthalmic  goiter  and  locomotor  ataxia. 


NEUROSES  OF  THE  INTESTINE  509 

In  the  latter  disease  it  sometimes  assumes  the  form  of  persistent  crises. 
Cases  in  which  diarrhea  follows  the  eating  of  certain  articles  of  food, 
harmless  to  other  people,  are  probably  of  this  nature. 

Symptoms. — The  only  symptom  in  many  cases  is  diarrhea.  This  is 
often  limited  to  two  or  three  watery,  pasty,  or  scybalous  passages  in  the 
morning.  In  other  cases  the  ingestion  of  food  is  immediately  followed 
by  an  imperative  demand  for  evacuation.  Intestinal  rumbling  or  gur- 
gling is  often  present  and  a  cause  of  embarrassment  to  the  patient. 
The  affection  often  runs  an  intermittent  course,  improvement  being 
broken  by  the  occurrence  of  any  nervous  irritation  or  worry. 

Diagnosis. — This  is  based  on  the  history,  the  character  of  the  diarrhea, 
and  the  nervous  condition  of  the  patient.  It  is  to  be  differentiated 
chiefly  from  acute  enteritis.  In  the  latter  affection,  the  attacks  often 
occur  at  night,  they  are  attended  with  pain  and  numerous  evacuations, 
often  with  vomiting,  and  usually  follow  a  definite  error  in  diet. 

Treatment. — All  treatment  is  useless  which  fails  to  remove  the  cause. 
On  this  account  a  change  of  scene,  removal  from  the  cause  of  worry,  and 
diversion  from  sorrow  are  more  important  than  drugs.  Relief  of  the 
neurasthenic  condition,  by  whatever  means,  is  promptly  followed  by  ar- 
rest of  the  diarrhea.  Astringents  are  seldom  beneficial,  and  opiates 
should  not  be  employed.  The  bromids,  ammonium  valerianate,  or  asa- 
fetida  is  beneficial  in  some  cases. 


ENTERALGIA. 
Colic,  Intestinal  Neuralgia,  Intestinal  Cramps,  Enterospasm,  Enterodynia. 

Definition.— A  disturbance  of  the  sensory  filaments  of  the  intestinal 
nerves,  producing  sharp  pain,  often  accompanied  with  localized  spasm 
of  the  muscular  coat  of  the  intestine. 

Etiology.— T\it  condition  occurs  at  any  age,  very  frequently  in  infancy 
and  childhood,  and  it  is  more  common  in  women. 

1.  Fredisposi/ig  Influences. — As  in  gastralgia,  there  is  often  a  consti- 
tutional disorder  back  of  it,  sometimes  apparently  a  hereditary  pre- 
disposition; a  neurotic  temperament,  improper  hygiene,  poor  health, 
chronic  disease  or  gastric  indigestion,  business  care  and  worry,  or  mental 
strain. 

2.  The  exciting  causes  are  :  Irritating  intestinal  contents,  toxemia,  or 
reflex  excitation. 

(rt;)  In  the  infant,  the  meconium,  if  too  long  retained,  may  cause 
irritation  (colica  meconialis) ;  in  the  adult  the  food  may  be  coarse  and 
irritating  in  quality,  or  decomposed,  or  the  chyme  may  lack  gastric 
digestion.  Unripe  fruit,  cold  and  acid  drinks  and  food,  are  common 
causes.  Retained  scybalous  masses,  foreign  bodies,  or  an  accumulation 
of  gas  may  cause  colic  through  pressure  or  stretching  of  the  intestinal 
wall. 

(Ji)  The  blood  may  contain  bacterial  toxins  which  are  irritating,  as 
in  cholera  and  malarial  cachexia,  or  such  poisons  as  uric  acid,  lead, 
copper,  or  arsenic. 

(r)  The  reflex  causes  are  many.  They  include  organic  disease  of  the 
brain  or  cord  and  the  crises  of  locomotor  ataxia,  hypochondriasis,  and 


5IO 


PRACTICE  OF  MEDICINE 


hysteria.     Chilling  of  the  surface  of  the  body  produces  enteralgia  in  some 
persons. 

Symptoms. — Pain  is  the  principal  symptom.  This  is  usually  referred 
to  the  umbilical  region,  from  which  it  may  radiate.  Sometimes  it  begins 
in  several  locations  at  the  same  time.  It  is  generally  periodical  and  it 
may  be  a  dull  aching  or  of  a  sharp,  lancinating  character,  usually  with 
increasing  intensity.  Tenderness  may  be  complained  of,  but  pressure  may 
give  relief,  and  the  patient  often  lies  on  the  stomach  or  with  the  knees 
drawn  up,  or  bends  over  a  chair.  The  abdomen  is  either  tympanitic  or 
retracted.  The  peristaltic  movements  of  the  bowel  may  be  visible.  Rum- 
bling noises  often  accompany  the  attack.  In  severe  cases  the  body  is 
bathed  in  a  profuse  sweat  and  the  face  becomes  pale.  Nausea  is  some- 
times complained  of;  vomiting  is  unusual.  The  pulse  is  generally  tense, 
but  slow.  Reflex  symptoms  may  be  observed,  as  palpitation,  dyspnea, 
hiccough,  rectal  or  vesical  tenesmus,  strangury,  priapism,  vertigo,  syn- 
cope, cramps  of  the  voluntary  muscles,  occasionally  convulsions.  The 
attack  may  last  only  a  few  minutes,  or  it  may  continue  for  hours  or 
days,  finally  ceasing  suddenly  or  gradually. 

Diagnosis. — The  condition  is  to  be  differentiated  :  (i)  From  peritonitis 
by  the  absence  of  fever  and  marked  abdominal  tenderness;  (2)  from 
appendicitis  by  the  absence  of  tenderness  at  McBurney's  point,  rigidity 
of  the  right  rectus,  fever,  and  induration;  (3)  from  intestinal  obstruc- 
tion by  the  absence  of  localized  tenderness,  obstinate  constipation,  and 
stercoral  vomiting;  (4)  hepatic  and  renal  colic  by  the  different  char- 
acter and  different  location  of  pain.  (5)  Rheumatism  of  the  abdominal 
walls  is  rare;  the  pain  is  superficial  and  aggravated  by  pressure  or 
movement.  (6)  In  lumboabdominal  neuralgia  the  pain  is  unilateral 
and  there  are  generally  characteristic  tender  points. 

The  prognosis  is  generally  favorable,  but  relapses  usually  occur,  unless 
the  cause  can  be  removed. 

Treatment. — This  is  directed  to  the  relief  of  pain  and  to  the  removal 
of  the  cause. 

In  severe  cases,  morphin  must  be  injected  hypodermically.  Mild  cases 
are  generally  relieved  by  the  administration  of  spirit  of  peppermint  or 
compound  spirit  of  sulphuric  ether,  with  camphorated  tincture  of  opium, 
chloroform  or  tincture  of  ginger,  capsicum  or  camphor,  or  various 
combinations  of  these  remedies.  Hot  poultices,  fomentations,  turpentine 
stupes,  and  the  hot-water  bag  are  serviceable  in  the  intervals. 

Removal  of  the  cause  embraces  :  Qa)  Relief  of  constipation  by  enemata 
and  laxatives;  (/;)  exclusion  of  irritating  articles  from  the  diet;  (r) 
remedies  to  assist  digestion,  when  any  of  these  causes  are  present.  (^) 
WTien  a  tendency  to  neuralgia  is  recognized,  arsenic  or  quinin  should  be 
employed.  (^)  A  gouty,  rheumatic,  neurotic  taint  and  the  various 
diseases  named  as  predisposing  causes  must  be  treated. 

MUCOUS  COLITIS. 
Membranous  Colitis,  Mucous  Colic,  Mucous  or  Tubular  Diarrhea. 

Definition.— A.  chronic  secretory  neurosis  of  the  intestine  characterized 
by  the  discharge  of  mucous  shreds  or  long  tubular  mucous  casts  of  the 
interior  of  the  colon. 


DISEASES  OF  THE  MESENTERY  511 

Etiology. — This  rather  rare  affection  may  occur  at  any  period  of  life, 
from  childhood  to  old  age,  but  is  more  prevalent  in  women,  particularly 
neurotic,  hysterical,  or  neurasthenic  subjects  and  those  debilitated  by 
organic  nervous  disease.  The  attack  is  commonly  induced  by  mental 
emotion  or  the  eating  of  improper  food. 

Morbid  Anatomy. — No  anatomical  lesions  are  present.  The  mucous 
shreds  and  casts,  when  detached,  leave  the  surface  of  the  mucosa  in  a 
normal  condition.     The  casts  consist  of  mucin,  not  fibrin. 

Symptoms. — The  disease  is  generally  marked  by  periodical  attacks  of 
enteralgia  accompanied  with  abdominal  tenderness  most  marked  at  the 
splenic  flexure  of  the  colon,  and  tenderness,  during  or  after  which  the 
characteristic  shreds  or  casts  are  discharged.  These  may  accompany 
defecation  or  pass  independently  of  it.  Pain  and  tenesmus  often  occur 
during  the  course  of  the  disease,  without  the  discharge  of  casts.  Disor- 
dered digestion  sometimes  precedes  the  attack  for  a  few  days.  The  pain 
may  be  severe,  and  pronounced  nervous  manifestations,  hysterical  in 
nature,  may  accompany  the  attack  or  develop  upon  the  discovery  of  the 
casts.  Constipation  is  usually  present.  Slight  hemorrhage  rarely  ac- 
companies the  extrusion  of  the  casts.  Fever  is  absent.  Emaciation 
results  from  long-continued  colitis.  The  attack  may  last  from  a  day  to 
a  week  or  longer,  and  the  disease  may  persist,  with  variable  intervals,  for 
many  years. 

Diagnosis. — The  casts  should  be  carefully  examined,  microscopically 
if  necessary,  in  order  to  exclude  fragments  of  tapeworm  or  undigested 
remnants  of  food,  as  the  skin  of  sausage,  husks  of  various  vegetables, 
or  the  pulp  of  orange  or  other  fruit.  The  differentiation  from  the  other 
painful  affections  of  the  abdomen  is  the  same  as  that  of  enteralgia. 

Prognosis. — Complete  cure  can  sometimes  be  secured  through  improve- 
ment of  the  general  health,  but  the  disease  is  a  stubborn  one.  Death 
has  occurred  during  the  attack. 

Treatment. — The  treatment  is  for  the  most  part  that  of  the  underlying 
condition.  The  painful  attack  should  be  relieved,  if  possible,  with  the 
carminatives  and  local  applications  recommended  for  enteralgia.  Mor- 
phin  should  not  be  given,  for  a  habit  is  readily  acquired  by  these  pa- 
tients. Constipation  is  to  be  relieved  and  the  diet  so  regulated  as  to 
avoid  irritation. 

Intestinal  Sand  (Sable  Intestinale).— It  occasionally  happens  that 
large  quantities  of  material  resembling  sand  or  gravel  pass  from  the 
bowels.  The  sandlike  particles  generally  consist  of  vegetable  sclerenchy- 
matous  matter,  sometimes  of  the  seeds  of  such  fruit  as  raspberries  or 
blackberries.  Very  rarely  biliary  sand  is  discharged.  True  intestinal 
sand,  consisting  of  the  carbonates  and  phosphates  of  calcium  and  mag- 
nesium, has  been  observed.  C.  H.  Bedford,  England,  reports  a  case  of 
this  character,  associated  with  colitis  and  constipation,  in  an  extremely 
gouty  woman  of  44  years. 

DISEASES  OF  THE   MESENTERY. 

The  mesentery  is  seldom  the  seat  of  primary  disease.  The  secondary 
affections  are  considered  in  connection  with  the  diseases  that  bear  a 
causal  relation  to  them,     (i)   Hemorrhage  is  rare  and  usually  associated 


512 


PRACTICE  OF  MEDICINE 


with  hemorrhagic  pancreatitis.  (2)  Embolism  and  thrombosis  of  the 
mesenteric  arteries  are  occasionally  encountered.  (See  Hemorrhagic  In- 
farction of  the  Intestine.)  (3)  The  mesenteric  artery  is  one  of  the  least 
frequent  sites  of  aneurism.  (4)  The  mesenteric  glands  are  enlarged  in 
typhoid  fever,  tuberculosis,  syphilis,  and  occasionally  in  Hodgkin's  dis- 
ease and  other  affections.  (5)  Malignant  growths,  hydatid,  chylous, 
and  other  cysts  sometimes  occur. 

DISEASES  OF  THE  LIVER. 

ANOMALIES  OF  FORM  AND   POSITION. 

Malformation  may  be  congenital  or  acquired,  (i)  Congenital  mal- 
formation is  rare.  The  only  examples  of  it  are  seen  in  livers  showing 
((2)  disproportion  in  the  size  of  the  lobes,  or  (/;)  lobulation,  which 
is  generally  a  result  of  hereditary  syphilis. 

(2)  Acquired  malformation  results  from  a  great  variety  of  influences, 
as:  ((1:)  The  corset  or  lacing  liver  of  women.  It  is  characterized  by  a  trans- 
verse groove  running  across  the  right  lobe  in  a  position  corresponding 
to  the  lower  margin  of  the  ribs.  In  extreme  cases  the  furrow  is  narrow 
and  deep  and  the  compressed  portion  is  transformed  into  fibrous  tissue 
with  hardly  a  vestige  of  hepatic  structure.  The  blood-vessels  are  to  a 
great  extent  obliterated.  The  lower  margin  of  the  organ  may  rest  be- 
tween the  umbilicus  and  crest  of  the  pubis.  Occasionally  the  liver  has  a 
pyramidal  shape,  with  the  apex  downward.  ((^)  Deformity  of  the  verte- 
hrae  or  ribs,  and  tumors  of  the  surrounding  organs  or  structures,  frequent- 
ly cause  an  alteration  of  the  shape  of  the  liver,  (r)  The  alterations  of 
size  and  form  due  to  disease  will  be  referred  to  in  their  proper  relations. 

Symptoms  may  be  absent.  In  some  cases  there  is  a  sensation  of  drag- 
ging or  pressure.  The  part  of  the  liver  below  the  constriction  becomes 
inflamed,  swollen,  and  painful.  Vomiting,  prostration  and  jaundice  oc- 
casionally occur,  especially  after  unusually  tight  lacing.  The  prominent 
lower  portion  of  the  liver  may  be  mistaken  for  a  neoplasm,  amyloid 
disease,  or  passive  hyperemia. 

Malposition. — The  liver  may  be  displaced  upward,  downward,  or  lat- 
erally,  and  the  displacement  may  be  congenital  or  acquired. 

(i)  Congenital  displacement  is  met  with  :  (^?)  In  the  rare  condition 
of  transposition  of  the  viscera,  when  it  occupies  a  position  on  the  left 
side  corresponding  to  its  normal  position  on  the  right.  (^)  The  organ 
may  be  found  in  a  hernia  of  the  diaphragm  or  abnominal  wall.  There 
ma,y  be  no  interference  with  its  function  in  these  cases.  (^)  The  so- 
called  suspensory  ligament  may  be  of  unusual  length,  permitting  descent 
or  lateral  movement.  In  extreme  cases  the  organ  lies  in  the  epigastric 
region  or  sinks  to  the  lower  part  of  the  abdominal  cavity, 

(2)  Acquired  Displacement.— (^a^  The  liver  may  be  raised  by  ascites, 
abdominal  tumor,  or  intestinal  distention,  (Ji)  It  may  be  lowered  by 
pleuritic  effusion,  emphysema,  or  an  intrathoracic  tumor  of  large  size, 
rarely  by   extensive  pericardial  effusion  or  subphrenic  abscess. 

Symptoms.— Tension  and  dragging  are  the  usual  symptoms.  There 
may  be  occasional  attacks  of  pain,  which  is  often  referred  to  the  right 
shoulder. 


DISEASES  OF  THE  LIVER  513 

Diagnosis. — The  condition  is  apt  to  be  confounded  with  various  neo- 
plasms of  the  stomach,  ovary,  uterus,  kidneys,  or  with  hydronephrosis 
or  pyonephrosis.  The  diagnosis  is  generally  based  upon  the  absence  of 
hepatic  dullness  in  the  usual  place,  but  this  sign  may  mislead  when  cir- 
rhosis or  fatty  degeneration  is  present. 

Treatment. — The  liver  can  generally  be  replaced  without  much  diffi- 
culty. A  suitable  bandage  should  then  be  worn  in  order  to  prevent 
recurrence  of  the  displacement. 

DISTURBANCES  OF  THE   HEPATIC  CIRCULATION. 

Anemia. — It  is  assumed  that  anemia  of  the  liver  accompanies  the 
general  deficiency  of  blood  after  profuse  hemorrhage  and  in  the  primary 
anemias.  The  liver  is  found  to  be  almost  bloodless  after  death  in  these 
conditions  as  well  as  in  amyloid  disease,  fatty  degeneration,  and  other 
conditions.  There  are  no  clinical  manifestations,  however,  through 
which  the  condition  can  be  recognized. 

Hyperemia  of  the  liver  is  a  condition  common  to  many  diseases. 
It  may  be  either  active  or  passive. 

1.  Active  Z(>;^^/-^?«/«  (Active  Congestion). — (^d)  A  physiological  hyper- 
emia of  the  liver  is  believed  to  occur  after  every  full  meal,  owing  to 
the  increased  activity  of  the  portal  circulation,  especially  if  alcohol  be 
ingested.  In  either  case  the  condition  is  transitory,  but  in  the  gor- 
mand  or  drunkard  it  leads  to  permanent  changes,  especially  to  cirrhosis. 
(/')  Other  causes  of  the  hyperemia  are  the  toxins  of  disease,  espe- 
cially those  of  malaria,  dysentery,  typhoid  or  typhus  fever,  erysipelas 
and  yellow  fever,  exposure  to  cold,  amenorrhea,  and  the  suppression  of 
habitual  hemorrhoidal  bleeding,  and  (^)  the  toxic  products  of  intra- 
intestinal  fermentation  and  such  intoxications  as  accompany  gout  and 
diabetes. 

The  symptoms  are  generally  due  to  associated  catarrh  of  the  stomach, 
duodenum,  or  bile-ducts.  There  may  be  a  sense  of  fullness  or  pain, 
slight  enlargement,  and  tenderness  of  the  liver;  less  commonly,  slight 
jaundice,  enlargement  of  the  spleen,  and  a  bilious  diarrhea. 

Treatment. — For  the  local  condition  a  calomel  or  saline  purge  is  in- 
dicated. Hot  or  cold  applications  to  the  hepatic  region  relieve  the 
abnormal  sensations.  Beyond  this  the  treatment  is  that  of  the  under- 
lying disease. 

2.  Passive  Hyperemia  (Chronic  Congestion  of  the  Liver,  Nutmeg 
Liver). — Etiology. — This  condition  results  from  obstruction  of  the  flow 
of  blood  from  the  liver,  (iz)  The  common  seat  of  obstruction  is  in  the 
heart.  Any  form  of  uncompensated  valvular  disease  may  excite  it, 
but  diseases  of  the  right  heart  act  more  directly.  It  may  result  also 
(J))  from  obstruction  of  the  pulmonary  circulation  as  in  emphysema, 
chronic  interstitial  pneumonia,  or  from  deformity  of  the  spine  or  exten- 
sive pleuritic  effusion ;  (r)  from  obstruction  of  the  ascending  vena  cava 
or  the  hepatic  vein  when  compressed  by  an  aneurism  or  other  tumor 
situated  anywhere  in  its  course.  (^)  The  condition  has  rarely  been 
caused  by  valves  or  other  projections  within  the  veins  or  by  the  presence 
of  constricting  bands. 

Morbid  Anatomy.— The  liver  is  uniformly  enlarged,  of  a  dark  red  or 

33 


514 


PR.\CTICE  OF  MEDICINE 


purple  color,  and  blood  flows  freely  from  a  cut  surface.  In  a  case  of 
long  duration,  however,  the  organ  may  appear  but  slightly,  if  at  all, 
enlarged,  owing  to  contraction  of  the  new  formed  connective  tissue 
(atrophic  nutmeg  liver).  Microscopic  examination  reveals  dilatation 
of  the  central  vein  with  thickening  of  its  walls,  hyperlasia  of  the  fibrous 
tissue,  with  pigmentation  of  the  cells  in  the  internal  zone  and  fatty 
infiltration  or  degeneration  of  those  in  the  outer  zone.  The  spleen  is 
usually  enlarged,  the  pancreas  larger  and  firmer  than  normal,  and  the 
kidneys  may  be  in  a  state  of  passive  congestion. 

Symptoms. — The  condition  seldom  attracts  attention  until  late  in 
the  history  of  the  case.  There  may  be  a  sensation  of  weight  and  full- 
ness or  even  pain  in  the  hepatic  region.  Gastrointestinal  disturbances 
are  common,  and  jaundice  may  develop.  Hematemesis  is  occasionally 
observed.  Clay-colored  stools  and  dark  urine  containing  bile  pigments 
usually  accompany  the  jaundice.  Ascites  and  anasarca  are  common, 
but  rather  as  manifestations  of  the  cardiac  than  of  the  hepatic  con- 
dition. Palpation  reveals  tenderness  and  enlargement  of  the  liver. 
In  extreme  cases  the  entire  organ  pulsates. 

Treatment. — The  treatment  is  directed  solely  to  the  affection  causing 
the  passive  congestion,  as  a  rule.  It  may  sometimes  be  necessary  to 
deplete  the  liver  by  purgation  or  to  relieve  pain  through  the  methods 
referred  to  under  Acute  Hyperemia. 

DISEASES  OF  THE  BLOOD-VESSELS  OF  THE  LIVER. 

Hemorrhage.— Hemorrhage  into  the  substance  of  the  liver  may  result 
from  (<z)  trauma,  ((^)  phosphorus-poisoning,  or  (r)  such  diseases  as 
purpura,  scurvy,  abscess,  leukemia,  malaria,  or  cancer.  There  may  be  a 
single  hemorrhage,  especially  after  injury,  or  numerous  small  hemorrhages. 
When  rupture  of  the  liver  has  occurred,  so  great  a  quantity  of  blood 
may  be  poured  into  the  peritoneal  cavity  as  to  induce  fatal  syncope. 

Embolism  and  Thrombosis  of  the  Portal  Vein.— (i)  Embolism.— 
The  branches  of  the  portal  vein  may  be  obstructed  by  emboH  originating 
in  the  stomach,  intestine,  pancreas,  or  spleen,  but  an  infarction  is  not 
generally  produced  owing  to  the  free  anastomosis  with  the  hepatic 
artery.    In  the  event  of  septic  emboH,  suppuration  is  developed. 

(2)  Thrombosis. — Thrombi  seldom  form  in  the  portal  vein.  They 
are  occasionally  met  with,  however,  as  a  result  of:  Qa)  Cirrhosis;  (/') 
cancer;  (<:)  sclerosis  with  roughening  of  the  vessel-wall;  (^)  local  in- 
flammation following  trauma,  abscess,  or  foreign  bodies;  (^)  slowing 
of  the  circulation  by  the  pressure  of  a  tumor,  enlarged  glands,  abscess, 
impacted  calculi,  or  proliferative  peritonitis. 

Morbid  Anatomy.  — The  thrombus  undergoes  the  usual  changes,  except 
that  organization  is  unusual.  In  rare  instances,  the  collateral  circulation 
becomes  complete  and  the  portal  vein  is  reduced  to  a  fibrous  cord  (pyle- 
phlebitis adhesiva).  Infarction  is  rare.  In  parietal  thrombosis  the  cir- 
culation may  be  gradually  restored. 

Symptoms.— The  symptoms  are  generally  slight  or  entirely  absent. 
When  the  obstruction  is  complete,  the  manifestations  are  the  same  in 
character  as  those  due  to  obstruction  in  hepatic  cirrhosis.  The  treat- 
ment is  also  the  same. 


ACUTE  HEPATITIS  515 

Suppurative  Pylephlebitis  (Suppurative  Inflammation  of  the  Portal 
Vein). — Etiology. — Septic  emboli  originate  from  processes  of  suppura- 
tion in  the  peritoneal  cavity,  most  frequently  from  an  appendiceal 
focus,  an  intestinal  or  gastric  ulcer,  or  suppuration  within  the  pelvis. 
It  sometimes  follows  infection  of  the  umbilicus  in  the  new-born  infant, 
or  it  may  be  a  part  of  a  general  pyemia. 

Symptoms. — («)  In  many  cases  the  condition  leads  to  the  formation  of 
one  or  many  distinct  abscesses.  (See  Abscess  of  the  Liver.)  (<^)  In  other 
cases  the  suppurative  process  remains  confined  to  the  portal  vein.  The 
liver  is  enlarged,  tender,  and  often  painful.  In  other  respects  the  symp- 
toms are  those  of  pyemia— irregular  fever,  occasional  chills  and  sweats 
with  enlargement  of  the  spleen,  headache,  loss  of  appetite,  scant  urine, 
jaundice,  and  diarrhea.  The  disease  usually  lasts  from  one  to  four 
weeks,  invariably  terminating  fatally,  generally  in  delirium  or  coma. 
The  diagnosis  is  often  extremely  difficult  in  the  absence  of  distinct  ab- 
scess-formation. 

Stenosis  of  the  Portal  Vein.— Extensive  obliteration  of  the  branches  of 
the  portal  vein  is  a  common  result  of  cirrhosis  and  syphilis.  Stenosis 
may  result  also  from  the  presence  of  thrombi  or  the  pressure  of  tumors. 

Symptoms  may  be  absent,  if  the  stenosis  form  slowly  and  permit 
the  establishment  of  compensatory  circulation.  When  it  is  due  to  throm- 
bosis, edema  and  ascites  may  suddenly  develop.  The  diagnosis  is  diffi- 
cult in  either  condition. 

Affections  of  the  Hepatic  Artery  and  Vein.— These  include  dilatations 
and  obliterations,  aneurism,  embolism,  thrombosis,  and  other  changes, 
for  the  most  part  due  to  secondary  inflammation,  pressure  by  tumors, 
adventitious  connective  tissue  in  cirrhosis,  and  the  various  lesions  of 
syphilis.  They  are  all  of  greater  interest  to  the  pathologist  than  to 
the  physician,  since  they  are  seldom  recognizable  during  iife. 

Hepatalgia. — An  independent  neuralgia  of  the  liver  is  believed  to  occur 
in  neurasthenic  cases,  or  in  connection  with  neuralgia  of  other  regions. 
It  is  thought  at  times  to  be  due  to  malarial  infection,  and  similar  pain 
accompanies  abscess,  neoplasms,  active  or  passive  hyperemia.  The  dif- 
ferentiation of  many  cases  from  the  colic  of  gall-stones  is  extremely 
difficult,  if  not  impossible.  The  treatment  is  usually  directed  against 
the  cause  of  the  affection ;  but  temporary  relief  may  be  afibrded  by  hot 
applications  and  counter-irritants, 

ACUTE  HEPATITIS. 

ACUTE   YELLOW  ATROPHY,  ACUTE  PARENCHYMATOUS    HEPATITIS,    MALIG- 
NANT JAUNDICE,  ICTERUS  GRAVIS. 

Definition. — An  acute  disease  of  the  liver  characterized  by  a  rapid 
destruction  of  the  parenchyma  cells,  and  consequent  atrophy  and  soften- 
ing of  the  organ,  with  jaundice,  hemorrhages,  and  grave  cerebral  mani- 
festations. 

Etiology. — i.  The  disease  is  rarely  primary.  It  has  usually  been  ob- 
served in  the  third  decade  of  life,  but  occasionally  in  infants.  2.  The 
secondary  form  is  not  at  all  frequent.  It  has  been  seen  with  appar- 
ently greater  frequency  in  some  localities  than  in  others,  and  groups 
of  cases  occasionally  occur  in  the  same  locality  within  a  comparatively 


51 6  PIL\CTICE  OF  MEDICINE 

short  time,  giving  them  the  appearance  of  an  endemic.  The  disease  is 
more  common  in  women.  Pregnancy,  puerperal  and  typhoid  fevers, 
diphtheria,  septicemia,  and  malaria  are  regarded  as  predisposing  causes. 
A  microbic  origin  has  been  suggested.  Acute  phosphorus-poisoning 
produces  a  rapid  fatty  atrophy  of  the  hver,  but  it  is  not  identical  with 
this  disease.  The  same  statement  doubtless  applies  to  the  fatty  necrosis 
which  is  a  terminal  stage  of  cirrhosis  and  obstructive  jaundice.  Some 
writers  assert  that  an  acute  yellow  atrophy  may  follow  a  debauch 
or  strong  mental  emotion. 

Morbid  Anatomy. — The  external  surface  of  the  body  is  extremely 
jaundiced.  The  degree  of  emaciation  is  variable.  The  liver  is  much 
reduced  in  size,  and,  as  a  rule,  so  flaccid  that  it  sinks  back  against 
the  posterior  wall  of  the  abdomen  as  soon  as  air  has  been  admitted. 
In  very  rare  cases  it  has  been  found  enlarged.  Its  external  color  is  a 
dirty  yellow.  On  section  it  may  be  uniformly  yellow,  but  there  are 
often  dark  red  patches  which  correspond  to  areas  from  which  all  the 
fat  has  been  absorbed.  After  exposure  to  the  air,  crystals  of  leucin 
and  tyrosin  are  formed  on  the  surface.  Microscopic  examination  reveals 
an  extreme  fatty  degeneration,  with  almost  complete  destruction  of  the 
cellular  elements.  A  variable  degree  of  cellular  infiltration  is  to  be  seen 
in  the  interstitial  connective  tissue,  and  here  and  there  clusters  of  cells 
that  are  regarded  as  new-formed  bile  capillaries.  Crystals  of  leucin  and 
tyrosin  are  present  in  varying  abundance.  The  heart  muscle  shows 
fatty  change,  the  spleen  is  enlarged,  the  kidney  epithelium  is  degenerated, 
and  the  entire  alimentary  tract  shows  catarrhal  changes.  The  pleural 
and  pericardial  fluids  are  often  increased. 

Symptoms. — i.  The  disease  usually  begins  as  a  gastrointestinal  catarrh, 
with  loss  of  appetite,  eructations,  nausea,  vomiting,  constipation  or  ir- 
regularity of  evacuation,  headache,  and  general  prostration.  In  a  few 
days  jaundice  begins  to  appear. 

2.  At  an  indefinite  time,  from  three  or  four  days  to  two  or  three 
weeks  from  the  beginning,  the  symptoms  suddenly  become  intensified. 
(^)  The  jaundice  deepens,  and  vomiting  becomes  constant.  The  vomit 
at  first  consists  of  bile-stained  stomach-contents,  later  containing  blood. 
((5)  The  headache  becomes  intense,  nervousness  develops,  and  the  patient 
may  finally  pass  into  a  maniacal  delirium,  (r)  Muscular  twitchings 
or  general  convulsions  are  sometimes  observed.  This  stage  is  often 
accompanied  with  (^)  hemorrhages  into  the  skin  (ecchymoses),  from 
the  nose,  stomach,  bowels,  kidneys.  (^)  The  temperature  is  variable; 
fever  may  be  absent  until  shortly  before  death,  when  hyperpyrexia 
often  develops.  An  afebrile  course  is  sometimes  observed,  and  a  sub- 
normal temperature  may  be  present  at  the  end.  (y )  During  the  severe 
stage,  the  size  of  the  liver  rapidly  diminishes  and  the  hepatic  region 
becomes  tender  and  often  intensely  painful.  (^)  The  spleen  is  usual!}' 
enlarged.  (^)  The  urine  becomes  scant,  deeply  bile-stained,  and  some- 
times albuminous.  The  urea  is  greatly  reduced  or  entirely  absent. 
Leucin,  tyrosin,  and  other  abnormal  products  of  less  importance,  as 
creatinin,  and  sarcolactic  acid,  are  usually  found  in  it.  Constipation 
is  generally  present  in  the  latter  part  of  the  disease,  the  stools  being 
clay-colored  from  absence  of  bile,  unless  they  be  darkened  by  the  pres- 
ence of  altered  blood. 


CIRRHOSES  OF  THE  LIVER  517 

Diagnosis. — The  recognition  of  the  disease  in  the  initial  stage  is  sel- 
dom possible.  When,  however,  the  acute  stage  develops  with  typical 
symptoms,  especially  if  in  a  pregnant  woman,  there  is  seldom  room 
for  doubt.  The  conditions  suggested  are  generally  limited  to  hyper- 
trophic cirrhosis  and  acute  phosphorus-poisoning.  Hypertrophic  cir- 
rhosis  affords  a  different  history ;  the  area  of  hepatic  dullness  is  greatly 
increased  and  the  urea  is  generally  increased.  The  last  is  a  more  valu- 
able symptom  than  the  absence  of  leucin  and  tyrosin.  Acute  phosphoriis- 
poisojiing  is  generally  recognized  by  the  history  of  the  ingestion  of  the 
poison,  the  sudden  onset,  with  nausea,  vomiting,  and  pain  in  the  liver, 
the  appearance  of  jaundice  on  the  second  or  third  day;  in  some  cases, 
by  phosphorescence  of  the  vomit  and  stools,  and  the  absence  of  leucin 
and  tyrosin  from  the  urine.  The  symptoms  ameliorate  after  the  appear- 
ance of  jaundice,  and  hematemesis  develops  toward  the  close  of  the  dis- 
ease. 

Prognosis. — The  primary  form  is  regarded  as  inevitably  fatal.  Re- 
coveries from  the  secondary  form  are  occasionally  reported. 

Treatment — All  measures  should  be  directed  to  the  comfort  of  the 
patient.  There  is  no  curative  treatment.  For  the  vomiting,  cracked 
ice,  dram  doses  of  paregoric,  and  other  remedies  should  be  employed. 
For  the  nervousness  or  delirium,  an  ice-bag  to  the  head  and  the  ad- 
ministration of  hydrobromic  acid,  chloral,  or  camphor  are  beneficial.  In 
extreme  cases,  hypodermic  administration  of  morphin  should  not  be 
withheld.  The  strength  of  the  patient  should  be  maintained  by  the 
most  nutritious  diet  and  free  stimulation  with  brandy  and  strychnin. 

CIRRHOSES  OF  THE  LIVER. 

Definition. — A  chronic  proliferative  inflammation  of  the  interstitial 
tissue  of  the  liver  which  results  in  atrophy  of  the  parenchyma  and  the 
production  of  circulatory,  gastrointestinal,  and  other  more  remote  dis- 
turbances. There  are  two  principal  forms  of  the  disease,  the  atrophic 
and  the  hypertrophic. 

ATROPHIC  CIRRHOSIS. 

Sclerosis  of  the  Liver,  Interstitial  Hepatitis,  Fibrous  Hepatitis,  Hobnail 

Liver,  Gin-Drinker's  Liver,  Alcoholic  Cirrhosis. 

Etiology. — i.  Sex  and  Age. — The  disease  is  commonly  seen  in  men 
from  40  to  60  years  of  age,  but  it  has  been  met  with  in  women,  and  in 
children  from  4  to  1 2  years  old.  In  children,  however,  it  is  usually  a 
manifestation  of  inherited  syphilis  or  a  result  of  one  of  the  acute  infec- 
tions, especially  scarlet  fever,  typhoid  fever,  intermittent  fever,  dysentery, 
or  tuberculosis,  influences  which  are  regarded  also  as  occasional  causes 
in  adults. 

2.  The  exciting  cause  is  an  irritation  of  the  connective  tissue,  (a) 
In  a  considerable  majority  of  all  cases,  the  irritation  is  produced  by 
alcohol  carried  to  the  liver  in  excessive  quantities  through  the  portal 
circulation.  ((^)  Some  other  influence  is  believed  by  some  writers  to 
be  operative  in  most  cases,  on  account  of  the  fact  that  the  disease  is 
by  no  means  universal,  even  among  habitual  drunkards.  It  is  believed, 
on  the  one  hand,   that  licjuor  containing  a  large  percentage  of  fusil  oil 


5i8  PRACTICE  OF  MEDICINE 

is  more  active  in  producing  the  disease.  The  disease  is  more  certain 
to  develop  in  those  who  drink  undiluted  whisky,  brandy,  gin,  or  rum  when 
the  stomach  is  empty,  than  in  those  who  take  their  "  eye-openers"  and 
"night-caps,"  with  a  nip  before  meals  for  an  appetite.  Some  few  have 
attributed  it  to  a  greater  extent  to  the  drinking  of  strong  wines.  In 
not  a  few  cases  there  is  a  history  of  former  syphilitic  infection,  and  this 
is,  no  doubt,  a  potent  element  in  etiology,  (r)  The  free  use  of  spices 
and  even  of  coffee  has  been  regarded  as  the  cause  of  the  disease.  (^) 
Poisoning  with  ptomains  is  now  regarded  as  an  important  factor  by 
some  investigators.  Autointoxication  due  to  the  indigestion  and  abnor- 
mal fermentation  excited  by  alcoholism  is  thought  to  hasten  the  inter- 
stitial inflammation.  (^)  Obstruction  of  the  bile-ducts  is  beheved  to 
cause  a  form  of  cirrhosis  in  some  instances.  (^)  The  disease  has  been 
produced  experimentally  in  a  fairly  typical  form  through  the  action  of 
lead,  silver,  arsenic,  antimony,  phosphorus,  butyric,  valerianic,  and  other 
organic  acids,  croton  oil,  and  carbolic  acid.  Dead  tubercle  bacilli  and 
the  toxins  of  several  bacteria  have  been  thus  employed,  administered 
with  the  food,  injected  into  the  hver  or  into  the  blood.  (/)  Syphihs 
of  itself  produces  a  form  of  cirrhosis  which  will  be  considered  separately. 
The  fibrous  induration  which  forms  about  foreign  bodies,  abscesses,  and 
other  inflammatory  products,  and  the  sclerosis  which  is  sometimes  seen 
as  a  result  of  chronic  passive  hyperemia,  are  not  proper  examples  of  the 
disease  under  consideration. 

Morbid  Anatomy. — Although  the  disease  is  recognized  cHnically  as  a 
progressive  one,  most  authors  describe  the  conditions  found  after  death 
as  belonging  to  one  or  other  of  two  types,  which  are  doubtless  different 
stages  of  the  same  process.  These  are  known  as  the  fibrous  or  atrophic 
and  the  fatty  forms.  The  essential  feature  in  each  is  the  excessive  for- 
mation of  fibrous  tissue  in  the  interstitial  spaces. 

(«)  Atrophic  Cirrhosis.— \n  this  form  the  new  connective  tissue  has 
undergone  marked  contraction  at  the  expense  of  the  parenchyma  cells, 
reducing  the  size  of  the  lobules,  and  consequently  that  of  the  entire 
organ.  Many  of  the  acini  are  entirely  destroyed,  many  remain  as  tufts 
of  comparatively  few  cells.  The  liver  is  greatly  diminished,  even  to  less 
than  half  its  normal  dimensions  and  weight,  and  it  is  much  firmer  than 
normal.  The  surface  is  roughened  by  numerous  depressions,  between 
which  are  the  "  hobnail"  prominences.  The  left  lobe  is  sometimes  convert- 
ed into  a  narrow,  hard,  fibrous  appendage  without  a  vestige  of  normal 
hver  tissue  in  it.  The  color  is  a  tawny  yellow,  sometimes  hghter,  some- 
times darker.  xA.nother  result  of  the  fibrous-tissue  contraction  is  the 
compression  and  obKteration  of  the  radicles  of  the  portal  vein  and 
of  the  smaller  bile-ducts.    Thrombophlebitis  is  sometimes  set  up. 

(J})  Fatty  Cirrhosis.— In  this  there  is  an  extreme  fatty  degeneration, 
sometimes  confined  to  the  outer  zone  of  the  lobule,  sometimes  affecting- 
all  parts  of  it  to  such  an  extent  that  scarcely  a  trace  of  Hver-cells  re- 
mains. The  pathological  process  has  generally  been  regarded  as  begin- 
ning in  the  fibrous  interstitial  tissue  and  affecting  the  parenchyma 
secondarily,  but  it  has  been  suggested  by  Weigert  and  others  that  the 
disease  begins  in  the  parenchyma.  The  size  of  the  organ  may  not  be 
so  markedly  reduced  as  in  the  fibrous  form,  but  there  is  pronounced 
obstruction  of  the  portal  circulation  in  extreme  cases. 


CIRRHOSES  OF  THE  LIVER  519 

Results  of  Portal  Obstruction. — i.  Anastomotic  communications  are 
established  between  the  branches  of  the  portal  vein  and  those  of  the 
vena  cava.  Almost  every  conceivable  avenue  of  communication  is  opened 
up  in  some  cases.  The  most  frequent  are  :  (<?)  Dilatation  of  the  veins 
in  the  suspensory  and  round  ligaments.  In  the  latter  a  large  vessel 
is  sometimes  found  which  is  regarded  by  some  as  a  reopening  of  the 
obliterated  umbilical  vein,  and  there  may  be  associated  with  it  a  coil 
of  dilated  vessels  around  the  umbilicus  known  as  the  caput  Medusae. 
((^)  A  free  communication  is  established  between  the  two  systems 
through  the  gastric  and  inferior  esophageal  veins;  (r)  through  the 
inferior  mesenteric  and  hemorrhoidal  veins;  (^)  through  the  retroperi- 
toneal plexus  of  veins,  reaching  the  kidneys  and  other  organs;  (^) 
through  the  epigastric  and  internal  mammary  veins. 

2.  Another  result  of  portal  obstruction,  although  possibly  influenced 
in  some  instances  by  the  development  of  endophlebitis,  is  an  accumu- 
lation of  fluid  in  the  peritoneal  cavity.  The  peritoneum  becomes  opaque, 
and  the  quantity  of  fluid  poured  out  is  sometimes  enormous.  Anasarca 
is  also  commonly  present. 

3.  The  spleen  is  almost  invariably  enlarged;  in  part,  perhaps,  as  a 
result  of  the  general  venous  tension;  possibly,  as  has  been  suggested, 
as  a  result  of  autoinfection.    The  kidneys  are  generally  hyperemic. 

A  common  result  of  the  obstruction  of  the  bile-ducts,  in  the  late 
stage  of  the  disease,  is  the  jaundice.  Rows  of  cells  suggestive  of  the  for- 
mation of  new  ducts  are  frequently  seen  in  the  microscopic  sections. 

Symptoms. — i.  The  early  manifestations  of  the  disease  are  indefinite. 
They  consist,  for  the  most  part,  of  digestive  disturbances,  anorexia, 
morning  nausea  or  vomiting,  constipation  or  diarrhea,  with  epigastric 
weight  and  hepatic  tenderness,  symptoms  which  may  be  attributed  with 
equal  propriety  to  the  gastric  and  intestinal  catarrh  consequent  upon 
the  direct  action  of  the  alcohol. 

2.  The  more  important  symptoms  of  cirrhosis  proper  are  due  to 
portal  obstruction,  (^a)  The  gastrointestinal  disturbances  become  more 
pronounced  and  more  constant,  the  appetite  capricious,  the  action  of 
the  bowels  irregular,  and  other  evidences  of  a  severe  gastrointestinal 
catarrh  develop.  (,5)  Hemorrhages  of  the  stomach  or  intestines  occur 
in  many  cases,  generally  in  an  advanced  stage  of  the  disease,  but  some- 
times early.  When  the  bleeding  is  confined  to  the  stomach,  the  blood  is 
vomited;  a  fatal  hematemesis  may  take  place.  Hemorrhage  in  the  in- 
testine leads,  to  melena,  or  tarry  stools.  Much  blood  is  often  lost  in 
the  course  of  the  repeated  hemorrhages,  for  they  may  recur  during  the 
course  of  a  year  or  more,  (^r)  Repeated  epistaxis  occurs  in  some  cases. 
(^d)  Hemorrhoids  are  generally  mentioned,  but  they  are  by  no  means 
uniformly  present.  (^)  Edema. — Ascites  does  not  usually  develop  until 
the  liver  has  undergone  considerable  atrophy,  but  it  is  one  of  the  most 
constant  and  characteristic  manifestations  of  the  disease.  Edema  of 
the  ankles  or  of  the  genitals  is  often  the  first  symptom  to  attract  the 
attention  of  the  pa,tient,  but  the  ascites  always  precedes  it.  The  quan- 
tity of  fluid  accumulated  is  often  enormous;  as  much  as  20  quarts 
(liters)  may  be  present.  After  tapping  has  been  performed,  the  fluid 
generally  reaccumulates  at  intervals  of  a  few  weeks  during  the  remainder 
of  life.    Toward  the  close,  the  edema  often  reaches  the  pleural  and  peri- 


530  PRACTICE  OF  MEDICINE 

cardial  cavities,  and  death  may  be  due  directly  to  edema  of  the  lungs. 
General  dropsy  is  unusual.  (/)  A  more  or  less  general  dilatation  of 
the  veins  over  the  surface  of  the  body  is  sometimes  observed,  and 
cutaneous  hemorrhages  may  occur.  All  these  manifestations  may  be 
prevented  by  an  early  development  of  compensatory  circulation,  or  they 
may  subside  after  its  development.  (^)  The  spleen  is  to  a  greater  or  less 
extent  enlarged  in  all  cases,  and  this  adds  to  the  abdominal  distention. 
(-^)  Jaundice  generally  appears  late  in  the  disease,  but  sometimes  com- 
paratively early.     It  is  ordinarily  slight  and  may  recur  at  intervals. 

3.  Toxic  symptoms  are  apt  to  develop  at  any  time  during  the  course 
of  the  disease.  They  generally  assume  the  form  of  a  mild  delirium. 
Their  exciting  cause  is  not  definitely  known.  They  often  develop  after 
weeks  of  abstinence  from  alcohol.  Uremia  and  cholemia  are  generally 
cited  as  the  probable  causes,  but  there  is  often  no  evidence  of  a  reten- 
tion of  either  urea  or  bile. 

4.  Fever  is  not  a  common  symptom,  but  it  occurs  at  times  in  some 
cases,  particularly  toward  the  close  of  the  disease  and  after  tapping. 

5.  With  the  progress  of  the  disease  the  patient  becomes  more  and 
more  emaciated.  The  face  becomes  sallow,  often  slightly  icteric;  the 
conjunctivae  especially  show  the  discoloration.  The  abdomen  becomes 
large  and  contrasts  strongly  with  the  wasted  extremities. 

6.  Physical  examination  reveals  slight  enlargement  of  the  liver,  possi- 
bly tenderness,  in  the  beginning,  but  later  the  area  of  dullness  is  greatly 
diminished.  The  roughened  surface  can  occasionally  be  felt.  The  spleen 
can  generally  be  recognized  on  palpation.  The  ascites  yields  character- 
istic dullness  and  fluctuation. 

7.  The  urine  is  generally  reduced  in  quantity,  always  deeply  colored, 
of  high  specific  gravity,  and  often  contains  albumin.  The  urea  is  usually 
diminished,  probably  on  account  of  deficient  production  in  the  liver. 

Diagnosis. — Th'e  disease  is  not  usually  recognizable  until  the  sclerosis 
has  become  well  established.  The  development  of  ascites  after  a  pro- 
longed gastrointestinal  catarrh  in  an  individual  long  addicted  to  exces- 
sive indulgence  in  alcohol,  especially  if  there  be  slight  jaundice,  the  he- 
patic fades,  and  emaciation,  is  generally  conclusive  evidence  of  cirrhosis. 
The  only  disease  to  be  excluded  in  most  cases  is  carcinoma.  Chronic 
or  tubercular  peritonitis  must  sometimes  be  considered. 

Carcinoma  is  generally  attended  with  greater  anemia,  fully  as  marked 
emaciation,  and  a  cachexia  that  is  quite  different  from  the  icteric  tinge. 
A  family  predisposition  can  often  be  traced.  The  liver  .is  generally 
enlarged  and  distinct;  umbilicated  nodules  can  often  be'felt  in  an  ad- 
vanced case.  The  difl'erentiation  is  often  difficult  in  a  case  of  primary 
carcinoma  affecting  an  alcoholic  subject. 

Chronic  or  tubercular  peritonitis  is  generally  attended  with  elevation 
of  temperature.  Tuberculosis  of  other  organs  may  be  found.  The  skin 
is  pale  and  anemic;  jaundice  is  not  present.  The  spleen  is  not,  as  a 
rule,  enlarged. 

Prognosis.— The  disease  is  incurable,  and,  as  a  rule,  it  runs  a  rapidly 
fatal  course,  except  in  those  rare  instances  in  which  the  drink  habit  is 
broken  off.  When  this  is  done,  the  patient  may  improve,  with  the  devel- 
opment of  anastomotic  circulation  and  the  relief  of  abdominal  tension 
through  tapping.     But  the  improvement  is  generally  only  temporary, 


CIRRHOSES  OF  THE  LIVER  521 

and  a  fatal  termination  may  be  anticipated  within  a   year    at    most 
after  the  occurrence  of  a  hemorrhage  or  the  development  of  ascites. 

Treatment. — All  possible  sources  of  irritation  to  the  liver  should  be 
promptly  removed.  The  ingestion  of  alcohol  must  be  stopped,  and  the 
diet  should  be  so  regulated  as  to  exclude  all  irritating  substances,  even 
coffee.  The  milk  diet  is  probably  the  best,  at  least  until  the  gastric  irri- 
tation has  subsided  and  the  more  active  hepatic  hyperemia  has  had  time 
to  abate.  The  bitter  tonics  should  be  employed  to  stimulate  the  appe- 
tite, especially  gentian  and  quassia,  and  dilute  hydrochloric  or  nitro- 
hydrochloric  acid  should  be  given  to  aid  digestion.  The  latter  acid 
was  formerly  thought  to  have  specific  action. 

An  attempt  to  diminish  the  ascitic  accumulation  may  be  made  through 
the  administration  of  diuretics,  especially  potassium  bitartrate  or  acetate, 
or  squill,  with  digitalis  in  suitable  cases.  But  it  is  generally  found 
necessary  to  resort  to  the  hydrogogue  purgatives,  as  compound  jalap 
powder,  every  morning,  or  eleterin  once  or  twice  a  week.  Carefully 
administered  Turkish  or  Russian  baths  are  often  of  great  benefit  in 
strong  patients. 

Tapping  becomes  necessary  in  most  cases.  It  does  not  require  the 
skill  of  a  surgeon,  but  it  should  be  performed  under  careful  antisepsis 
with  a  large  aspirator  needle  or  a  trochar  introduced  in  the  median 
line  about  midway  between  the  umbilicus  and  the  pubis,  the  patient 
sitting,  and  after  evacuation  of  the  bladder.  A  more  extensive  surgical 
treatment  has  been  employed  in  a  few  cases,  the  abdomen  being  opened, 
and  the  surface  of  the  liver  and  peritoneum  thoroughly  scrubbed  in  order 
to  induce  adhesive  inflammation. 

Hemorrhage  is  best  controlled  by  cold  applications  to  the  abdomen 
and  the  administration  of  opium  in  full  doses.  Ergot  is  employed  by 
some  physicians ;  astringents  are  useless. 

Potassium  iodid  may  be  employed  when  there  is  a  history  of  syphilis, 
or  experimentally  in  one  who  denies  such  infection,  but  it  is  not  of  bene- 
fit in  simple  alcoholic  cirrhosis,  even  when  it  affects  a  syphilitic  subject. 
Its  effect  in  syphilitic  cirrhosis  is  quite  marked,  especially  in  the  early 
part  of  the  disease. 

A  return  to  alcoholic  stimulation  may  become  necessary  late  in  the 
course  of  the  disease,  simply  as  a  means  of  prolonging  the  patient's 
existence. 

HYPERTROPHIC  CIRRHOSIS. 
Hanot's  Disease. 

Definition. — A  rare  form  of  hepatic  sclerosis  attended  with  marked 
increase  in  the  size  of  the  liver. 

Etiology.— T\\Q  disease  is  generally  observed  in  men  during  early  adult 
life,  but  it  sometimes  attacks  women  or  children.  The  exciting  cause 
is  not  known.  There  is  no  evidence  that  it  is  to  any  extent  caused 
by  alcoholism.  In  one  form  of  the  disease  (biliary  cirrhosis),  it  is  be- 
lieved to  originate  from  an  obstruction  of  the  bile-ducts  with  calculi. 

Morbid  Anatomy. — The  liver  is  uniformly  enlarged,  its  surface  is  smooth 
or  slightly  granular,  and  the  section  shows  a  tawny,  cirrhotic  color. 
Histologically,  the  appearances  are  the  same  as  those  of  atrophic  cir- 
rhosis, except  that  the  hyperplastic  connective  tissue  shows  no  tendency 


522  PRACTICE  OF  MEDICINE 

to  contract.  A  new  growth  of  bile  capillaries  is  believed  to  take  place, 
especially  in  the  biliary  form.  The  liver  cells  sometimes  appear  hyper- 
trophied;  but  fatty  degeneration  and  destruction  of  the  cells  do  not 
occur,  as  in  the  atrophic  form.  The  spleen  is  enlarged  and  the  abdomen 
is  distended,  but  there  is  no  ascites. 

Symptoms.— 1.  Enlargement  of  the  liver  is  often  the  first  manifes- 
tation of  the  disease.  Either  lobe  or  the  entire  organ  may  become 
prominent.  The  lower  margin,  sometimes  found  below  the  level  of  the 
umbilicus,  is  sharp  and  firm.  The  surface  feels  smooth.  The  gall-bladdet 
is  not  enlarged.  2.  Jaundice  often  appears  early  and  persists  through- 
out the  long  course  of  the  disease.  It  is  at  first  slight,  but  later  may 
become  extreme.  A  febrile  jaundice  (icterus  gravis),  with  delirium, 
may  develop  at  any  time  during  the  course  of  the  case.  The  tempera- 
ture runs  up  rapidly,  even  to  108°  F.  (42.2°  C),  and  death  may  ensue, 
in  delirium  or  coma. 

3.  Paroxysms  of  pain  and  tenderness  in  the  region  of  the  liver  some- 
times occur,  with  nausea  and  vomiting.  They  may  be  the  first  symp- 
toms. 

4.  Hemorrhages  are  a  prominent  feature  from  an  early  period.  There 
may  be  bleeding  from  the  nose,  gums,  stomach,  or  intestines;  or  a  pur- 
pura may  develop. 

5.  Other  features  are :  ((j;)  A  chronic  course,  sometimes  lasting  5  or 
10  years;  ((^)  an  enlargement  of  the  spleen;  (<;)  the  absence  of  ascites; 
(^)  urticaria  and  other  eruptions,  occasionally  noted;  (^)  the  urine 
contains  bile  pigment  and  the  stools  are  dark;  they  do  not  show  the 
clay  color  of  obstructive  jaundice. 

Diagnosis. — This  is  based  on  :  (a)  The  chronic  enlargement  of  the 
liver  and  spleen;  (<^)  the  persistent  jaundice;  (<:•)  a  tendency  to  hemor- 
rhages ;  and  (^)  the  absence  of  ascites.  The  affection  is  to  be  differen- 
tiated especially  from  amyloid  disease,  sometimes  from  abscess  or  car- 
cinoma of  the  liver,  or  echinococcus  cyst. 

Amyloid  disease  follows  a  history  of  suppuration,  tuberculosis,  or 
syphilis;  the  skin  is  waxy,  seldom  jaundiced.  The  liver  is  hard,  and 
other  organs  are  affected.  Abscess  usually  follows  dysentery ;  its  course 
is  febrile  and  of  shorter  duration.  The  hepatic  enlargement  soon  be- 
comes sensitive,  and  fluctuation  develops.  Carcinoma  is  differentiated 
under  Atrophic  Cirrhosis.  In  echinococcus  cysts  the  enlargement  is  cystic, 
and  hydatid  purring  may  be  felt.  The  aspirator  withdraws  character- 
istic fluid. 

Treatment. — The  treatment,  like  that  of  atrophic  cirrhosis,  is  chiefly 
symptomatic,  and  at  best  has  little  influence  on  the  course  of  the  dis- 
ease. 

Syphilitic  Cirrhosis. — The  syphilitic  diseases  of  the  liver  are  con- 
sidered in   the  general  chapter  on  Syphilis  (p.   164). 

PERIHEPATITIS. 

CAPSULAR  CIRRHOSIS. 

An  acute  and  a  chronic  form  of  perihepatitis  are  recognized. 
I.   Acute  Perihepatitis   (Subphrenic  or  Subdiaphragmatic    Pyopneu- 
mothorax,   Subphrenic    Abscess). — A    fibrinous    or    suppurative  inflam- 


PERIHEPATITIS  523 

mation  involving  the  contiguous  surfaces  of  the  hepatic  and  diaphrag- 
matic peritoneum. 

Etiology. — The  disease  is  rarely  primary  except  when  the  result  of  in- 
jury. The  principal  causes  of  fibrinous  perihepatitis  are  :  (^a)  Extension 
of  inflammation  from  a  diaphragmatic  pleurisy  or  empyema;  (/^)  abscess 
or  cyst  of  the  liver,  gall-bladder,  right  kidney,  or  contiguous  parts. 
The  suppurative  form  may  arise  from  any  of  these  causes,  but  is  more 
commonly  a  result  of  the  perforation  of  gastric,  duodenal,  or  other  intes- 
tinal ulcers,  particularly  of  appendiceal  perforation.  It  occasionally  de- 
velops in  pneumonia  or  malignant  disease. 

Morbid  Anatomy. — The  conditions  are  the  same  as  those  found  in  a 
fibrinous  or  suppurative  peritonitis.  A  localized  abscess  is  usually 
formed  by  the  growth  of  adhesions.  When  a  perforation  has  caused  the 
condition,  the  pus  is  mingled  with  gas  (subphrenic  pyopneumothorax). 
Bile  pigment  and  fatty  acids  may  be  found  in  the  pus. 

Symptoms. — The  most  prominent  of  these  are  :  («)  Local  pain  and 
tenderness,  increased  by  deep  respiration;  (^)  fever,  especially  in  the 
suppurative  form,  when  chills  and  other  indications  of  sepsis  are  com- 
monly present;  (^)  dyspnea,  as  a  result  of  the  pressure  of  the  sub- 
phrenic abscess.  (^)  Examination  reveals  generally  a  downward  dis- 
placement of  the  liver,  and  marked  prominence  of  the  abdominal  wall 
above;  the  skin  may  be  inflamed  and  edematous;  percussion  reveals 
tympanites  or  flatness  corresponding  to  the  presence  or  absence  of  gas. 
A  friction  fremitus  and  crepitation  are  sometimes  felt  and  heard  over  the 
region.  (^)  Rupture  of  the  abscess  may  pour  the  contents  into  the 
pleural  or  general  peritoneal  cavity,  rarely  outward  through  the  skin. 
The  disease  is  differentiated  from  empyema  of  the  right  side  chiefly  by 
the  abdominal  character  of  the  early  symptoms,  by  the  downward  dis- 
placement of  the  liver,  the  absence  of  cardiac  displacement,  and  other 
indications  of  empyema.  Pus  may  be  withdrawn  by  introducing  a  tro- 
char  at  the  seventh  or  eighth  intercostal  space.  The  flow  is  strong  and 
is  not  arrested  by  inspiration  as  it  is  in  pleuritic  effusion  (Pfuhl's  sign). 

Prognosis. — Acute  fibrinous  cases  usually  terminate  favorably;  the 
suppurative  form,  unless  arrested  by  early  surgical  procedure,  is  exceed- 
ingly fatal.  Recovery  occasionally  follows  the  spontaneous  evacuation 
of  the  pus. 

The  treatment  is  the  same  as  that  of  localized  peritonitis,  with  the 
addition  of  surgical  measures  for  the  suppurative  form. 

2.  Chronic  Perihepatitis  (Chronic  Hepatic  Capsulitis,  Capsular  Cir- 
rhosis, Glissonian  Cirrhosis). — A  chronic  inflammation  of  the  serous 
covering  of  the  liver,  resulting  in  marked  thickening  and  contraction, 
sometimes  producing  deformity  or  atrophy  of  the  organ,  with  or  without 
sclerosis  of  its  interstitial  tissue. 

Etiology. — The  disease  is  peculiar  to  adult  life  and  is  usually  accom- 
panied with  perisplenitis,  chronic  interstitial  nephritis,  and  chronic  prolif- 
erative peritonitis  or  possibly  chronic  mediastinitis.  Syphilis  is  regarded 
by  Anders  as  a  frequent  cause,  and  tight-lacing  has  been  mentioned. 
Its  origin  is  generally  obscure  unless  traceable  to  inflammation  in  ad- 
jacent tissues. 

Morbid  Anatomy. — The  capsule  is  much  thickened.  The  liver  is  greatly 
reduced  in  size  as  a  result  of  compression. 


524  PRACTICE  OF  MEDICINE 

Symptoms. — These  are  usually  vague.  Persistent  or  recurrent  ascites^ 
with  reduction  of  the  liver  outlines,  pain,  and  tenderness,  associated  with 
the  manifestations  of  chronic  interstitial  nephritis,  are  the  most  frequent 
indications  of  the  disease. 

The  treatment  is  the  same  as  that  of  atrophic  cirrhosis. 


ABSCESS  OF  THE  LIVER. 

SUPPURATIVE   HEPATITIS. 

Definition. — A  suppurative  inflammation  affecting  the  substance  of 
the  liver. 

Etiology. — i.  The  tropical  abscess,  usually  single,  is  generally  met  with 
in  adult  males.  It  is  especially  common  in  India  and  other  tropical 
countries;  less  so  in  our  Southern  States,  and  cases  occur  occasionally 
in  the  North,  (a)  Idiopathic  cases  are  recognized,  cases,  at  least,  in 
which  there  is  no  history  of  previous  disease.  (^)  The  disease  is  much 
more  frequently  a  sequel  of  dysentery,  (t^)  The  ameba  coli,  streptococci, 
and  staphylococci  are  found  in  the  pus,  and  the  ameba  especially  is  re- 
garded as  a  cause  of  the  disease,  since  it  is  to  be  found  in  the  stools,  even 
independently  of  dysentery.  Overindulgence  in  liquor,  particularly  by 
European  residents  of  the  tropics,  is  thought  to  be  influential  in  some 
cases,  possibly  by  developing  duodenal  and  biliary  catarrh. 

2.  JEmbolic  abscesses  axtrvotireciVitTit.  They  develop:  («)  Generally  as 
a  result  of  infection  through  the  portal  v'ein,  in  .connection  with  appendi- 
citis, typhoid  fever,  dysentery,  or  the  various  intestinal  ulcers ;  (^b )  less 
frequently  through  the  hepatic  artery,  as  from  an  ulcerative  endocarditis; 
(r)  rarely,  perhaps,  through  the  vena  cava  and  hepatic  vein,  from  a 
gangrenous  focus  in  the  lungs ;  Qd)  the  disease  is  often  a  part  of  a  gen- 
eral pyemia. 

3.  The  traumatic  abscess  usually  results  from  direct  injury  of  the  liver; 
occasionally  it  follows  injury  of  the  head. 

4.  Suppurative  colatigitis,  inflammation  of  the  bile-passages,  due  to 
the  lodgment  of  gall-stones,  to  tuberculosis,  or  an  extension  of  duodenal 
inflammation,  is  an  occasional  cause,  especially  of  multiple  abscesses. 

5.  Foreig7i  bodies,  as  needles,  pins,  or  fishbones,  and  such  parasites 
as  round  worms,  echinococci,  or  the  distoma,  acting  as  foreign  bodies, 
sometimes  produce  abscesses. 

Morbid  Anatomy. — As  a  rule,  there  is  a  single  large  abscess;  occasion- 
ally there  are  several  of  considerable  size  or  numerous  small  ones  (in 
the  pyemic  form). 

I.  The  solitary  or  tropical  abscess  is  usually  single.  It  may  have 
a  capacity  of  five  or  six  quarts  (liters),  excavating  more  than  half 
the  entire  liver,  and  is  then  generally  confined  to  the' right  lobe.  It 
is  only  in  abscesses  of  long  standing  that  there  is  a  distinct  limiting 
wall.  In  those  of  more  recent  development  the  inner  surface  is  necrotic, 
ragged ;  and  beneath  this  there  is  a  transition  from  necrotic  to  inflamed 
liver  tissue.  The  pus  is  of  different  colors,  from  white  to  brown  or  green, 
often  peculiar  in  odor  and  possibly  containing  amebae,  staphylococci, 
streptococci,  or  colon  bacilli.  It  is  sometimes  sterile.  Rupture  of  the 
abscess  is  not  uncommonly  discovered.    The  pus  may  be  found  to  have 


ABSCESS  OF  THE  LIVER  525 

perforated  the  right  pleural  cavity,  the  peritoneal  cavity,  the  bile-ducts, 
gall-bladder  or  colon,  rarely  even  the  pericardium  or  vena  cava. 

2.  Multiple  or  pyemic  abscesses  may  be  extremely  numerous,  but  a 
single  abscess  of  pyemic  origin  is  occasionally  met  with.  The  pus 
varies  in  appearance  as  in  other  abscesses  and  is  often  bile-stained. 
When  an  obstructive  colangitis  is  present,  gall-stones  are  usually  found, 
and  extensive  suppurative  inflammation  may  extend  through  almost 
the  entire  system  of  bile-ducts  and  the  gall-bladder.  Suppuration  about 
foreign  bodies  and  parasites  is  often  quite  extensive,  but  a  distinct  ab- 
scess is  usually  formed. 

Symptoms. — i.  The  Solitary  Abscess. — The  severity  of  the  symptoms 
varies  in  different  cases.  Death  sometimes  occurs  from  the  rupture  of  an 
abscess,  especially  in  the  tropics,  before  the  condition  has  been  recognized. 
In  most  cases,  however,  the  condition  is  recognized  through  local  pain 
and  tenderness,  enlargement  of  the  liver,  and  elevation  of  temperature, 
with  other  indications  of  sepsis. 

(^a)  The  pain,  usually  of  a  dull  aching  character,  may  be  confined  to 
the  hepatic  region,  but  is  generally  referred  to  the  back  and  shoulder. 
The  tenderness  is  usually  greatest  at  the  margin  of  the  ribs  in  the 
mammary  line.  A  dragging  sensation  is  sometimes  complained  of  when 
the  patient  lies  upon  the  left  side. 

QT)  The  enlargement  is  confined  in  most  cases  to  the  right  lobe 
and  is  greatest  above  and  to  the  right,  so  that  the  line  of  dullness  in 
the  axillary  line  is  often  as  high  as  the  fifth  interspace,  and  it  may 
rise  posteriorly  nearly  to  the  angle  of  the  scapula.  The  prominence 
may  be  distinctly  visible.  Palpation  often  reveals  decided  tenderness, 
■especially  when  deep  pressure  is  made.  Fluctuation  is  sometimes  de- 
tected. After  adhesions  have  formed  between  the  peritoneal  surfaces  over 
the  abscess,  the  skin  becomes  red  and  edematous,  as  "pointing"  pro- 
gresses. 

(^)  The  fever  is  usually  of  an  intermittent  type,  or  it  may  be  irreg- 
ular. It  is  sometimes  accompanied  with  chills,  sweating,  and  other 
indications  of  sepsis.  The  case  often  resembles  one  or  other  of  the  forms 
of  malaria,  or  it  may  suggest  a  cachectic  condition.  In  the  more  chronic 
cases  fever  may  be  absent,  but  the  appearance  of  the  patient  becomes 
highly  distinctive.  The  face  is  pale,  generally  sallow,  the  skin  is  usually 
slightly  icteric,  seldom  deeply  so.  Constipation  may  be  present,  but 
diarrhea  is  a  more  usual  condition ;  nausea,  vomiting,  and  other  indica- 
tions of  digestive  disturbance  are  common.  Ascites  sometimes  develops. 
Pressure  symptoms,  especially  dyspnea  and  cough,  commonly  result 
from  the' elevation  of  the  diaphragm,  and  a  suppurative  pleurisy  is  some- 
times induced  without  actual  rupture  of  the  abscess.  When  rupture 
occurs,  the  pus  is  discharged  in  any  of  the  directions  already  referred  to, 
especially  into  the  pleural  or  peritoneal  cavity  or  one  of  the  hollow 
viscera.  The  case  may  terminate  fatally  from  the  results  of  perforation 
or  from  profound  septicemia.  The  duration  of  the  disease,  when  not 
relieved  through  surgical  measures,  is  exceedingly  indefinite,  varying  from 
■one  or  two  months  to  as  many  years. 

2.  Pyemic  Abscesses. — Although  the  liver  may  be  extensively  involved, 
the  condition  may  escape  notice,  especially  when  it  is  a  part  of  a  general 
septic  infection.    The  symptoms,  aside  from  slight  pain,  localized  tender- 


526  PRACTICE  OF  MEDICINE 

ness,  and  some  enlargement  of  the  organ,  and  perhaps  an  icteric  tinge 
of  the  skin,  are  those  of  septicemia  or  pyemia.  The  condition  can  rarely, 
if  ever,  be  distinguished  from  that  due  to  a  suppurative  pylephlebitis. 

Diagnosis. — The  diseases  most  frequently  to  be  excluded  are  malaria, 
empyema,  pylephlebitis  from  impaction  of  calculi,  and  other  affections 
causing  enlargement  of  the  liver. 

Malaria  is  most  likely  to  be  suspected  in  tropical  and  other  malari- 
ous regions.  It  is  readily  excluded,  however,  by  the  absence  of  Plas- 
modia or  free  pigment,  and  the  presence  of  a  decided  leucocytosis.  The 
fever  resists  quinin.  In  malaria  there  is  usually  a  history  of  previous 
attacks,  and  the  temperature  curve  is  more  uniform.  If  chills  occur, 
they  are  at  more  definite  intervals  than  in  sepsis.  The  spleen  becomes 
enlarged,  and  the  color  of  the  skin  is  usually  darker  than  that  accom- 
panying abscess. 

Empyema  of  the  right  side  gives  us  a  history  of  pleuritic  pain,  pos- 
sibly of  injury  to  the  chest  or  the  rupture  of  a  tuberculous  or  emphy- 
sematous cavity,  the  side  of  the  thorax  becomes  distended,  the  inter- 
costal spaces  obliterated,  the  lung  is  displaced  upward,  the  heart  is 
pushed  to  the  left,  and  the  fluid  level  changes  with  change  of  position. 
The  aspirator  needle  reveals  pus  above  the  diaphragm,  not  below  it. 
When,  however,  a  hepatic  abscess  ruptures  into  the  pleural  cavity,  an 
empyema  is  set  up  with  a  history  of  previous  subdiaphragmatic  symp- 
toms. 

Pylephlebitis  occasions  symptoms  not  readily  distinguishable  from 
abscess,  and  the  suppurative  form  sometimes  leads  to  the  formation  of 
localized  abscess.  The  attacks  of  pain,  jaundice,  fever,  chills,  and  sweats 
which  characterize  the  disease  are  accompanied  with  clay -colored  stools, 
and  calculi  are  often  found  in  them. 

Other  conditions  occasionally  to  be  diiferentiated  are  carcinoma, 
hypertrophic  cirrhosis,  and  hydatid  cyst.  Abscess  in  the  abdominal 
wall  must  often  be  excluded.  In  all  cases,  the  diagnosis  should  be  con- 
firmed by  means  of  the  aspirator  needle. 

Prognosis. — Hepatic  abscess  is  in  itself  inevitably  fatal,  except  in  those 
rare  cases  in  which  spontaneous  evacuation  is  followed  by  recovery. 
Cases  of  single  large  abscess  amenable  to  surgical  treatment  frequently 
recover,  but,  although  the  cavity  can  be  evacuated,  complete  recovery 
is  often  long  delayed  or  never  attained.  Multiple  pyemic  abscesses  are 
almost  necessarily  fatal,  but  the  hepatic  conditions  may  contribute  but 
little  to  the  fatal  issue. 

Treatment. — Aside  from  surgical  measures  for  the  evacuation  and 
obliteration  of  the  abscess  cavity,  the  treatment  is  wholly  symptomatic. 
The  nutrition  and  strength  of  the  patient  are  to  be  supported,  and  suf- 
fering relieved.  In  many  cases  the  treatment  resolves  itself  into  that  of 
the  septic  condition.     (See  Treatment  of  Septicemia  and  Pyemia.) 

FATTY  LIVER. 

The  liver  is  subject  to  both  fatty  infiltration  and  fatty  degenera- 
tion.    (See  pp.  2  2  and  23.) 

Efio/ogy.— The  condition  results  from  :  (<?)  Obesity,  a  condition  in 
which  the  liver  serves  as  one  of  the  storehouses  for  redundant  fat ;  (^) 


FATTY  LIVER 


527 


from  the  prolonged  action  of  alcoholic  or  malt  liquors,  or  such  poisons 
as  phosphorus,  arsenic,  or  chloroform,  conditions  in  which  the  degenera- 
tion is  probably  due  to  diminished  supply  of  oxygen  to  the  tissues ;  and 
(r)  from  acute  infections,  as,  perhaps,  in  acute  yellow  atrophy,  pro- 
found anemia,  or  the  cachetic  states  associated  with  tuberculosis,  cancer, 
chronic  dysentery,  or  other  chronic  wasting  disease. 

Morbid  Anatomy.— The  organ  may  be  normal  or  atrophic,  but  it  is 
generally  enlarged.  The  surface  is  smooth,  the  color  a  pale  yellow,  and 
the  consistence  is  diminished. 

Symptoms. — There  are  sometimes  no  manifestations  by  which  the  dis- 
ease can  be  recognized  during  life.  When  the  liver  is  found  to  be  much 
enlarged  in  connection  with  obesity  or  during  the  course  of  the  chronic 
cachectic  diseases,  a  fatty  degeneration  is  probable. 

Diagnosis. — The  fatty  liver  is  to  be  distinguished  from  the  amyloid 
chiefly  by  the  absence  of  suppuration  as  a  cause.  As  both  affections 
occur  in  connection  with  tuberculosis,  the  differentiation  is  generally 
reduced  to  the  comparative  firmness  or  softness  of  the  organ,  which  can 
be  recognized  best  along  the  lower  margin,  and  the  presence  of  amyloid 
disease  in  other  parts.  From  hypertrophic  cirrhosis  fatty  liver  can  be 
distinguished  by  the  absence  of  jaundice  and  other  evidences  of  portal 
and  biliary  obstruction,  taken  in  connection  with  the  history  of  the  case. 
From  carcinoma  it  is  distinguished  by  the  uniform  smoothness  of  the 
surface  and  the  absence  of  nodules,  profound  emaciation,  pain,  and  ca- 
chexia. From  leukemia  it  is  distinguished  through  examination  of  the 
blood. 

Treatment. — The  treatment  is  that  of  the  condition  upon  which  the 
fatty  infiltration  or  degeneration  depends.  It  is  seldom  that  the  con- 
dition of  the  liver  need  be  made  the  object  of  special  treatment. 


AMYLOID  LIVER. 

WAXY  OR  LARDACEOUS  LIVER. 

Etiology. — For  the  causes  of  amyloid  disease  see  page  2t,. 

Morbid  Anatomy. — The  liver  becomes  enormously  enlarged  and  ex- 
ceedingly firm,  the  surface  smooth,  color  lighter  than  normal,  and  the 
cut  surface  anemic.  An  atrophied  liver  in  a  state  of  amyloid  degenera- 
tion has  been  described.  The  usual  reactions  of  amyloid  tissue  to  iodin 
and  the  anilin  stains  can  be  obtained. 

Symptoms  and  Diagnosis. — Few  or  no  disturbances  are  occasioned  by 
even  advanced  amyloid  disease  of  the  liver.  The  lower  margin  may  be 
felt,  firm  and  sharp,  as  low  in  the  abdomen  as  the  umbilicus,  sometimes 
even  at  the  pelvic  brim,  and  the  surface  is  everywhere  smooth.  The 
spleen  is  usually  enlarged  on  account  of  the  same  disease  in  it,  and  the 
diagnosis  rests  upon  the  history  of  suppuration,  with,  perhaps,  syphilis 
or  tuberculosis  in  the  background,  the  evidences  of  the  disease  elsewhere, 
and  the  peculiar  waxy  pallor  of  the  skin.  The  blood  should  be  examined 
in  order  to  exclude  the  enlargement  due  to  leukemia. 

Prognosis. — The  disease  is  incurable,  but  the  result,  as  it  affects  life, 
depends  more  upon  the  condition  of  other  organs,  especially  that  of  the 
intestines  and  kidneys. 


528  PRACTICE  OF  MEDICINE 

Treatment. — There  is  no  treatment  for  amyloid  disease,  and,  so  far  as 
the  Hver  is  concerned,  there  is  Httle  call  for  medication.  It  is  doubtful 
if  treatment  of  the  underlying  condition  is  capable  of  arresting  to  any 
extent  the  progress  of  the  disease. 

CANCER  OF  THE  LIVER. 

Etiology. — Cancer  of  the  liver  is  primary  in  less  than  5  per  cent  of 
cases.  It  is  usually  secondary  to  the  same  type  of  cancer  in  the  stom- 
ach, pancreas,  gall-bladder,  rectum,  or  other  organ.  The  most  impor- 
tant of  the  recognized  causes  are  :  («)  Age. — More  than  half  the  cases 
occur  between  the  40th  and  60th  year,  and  few  before  30,  but  cases 
have  been  reported  in  children.  (^)  Sex. — Men  are  somewhat  more 
frequently  affected  than  women,  notwithstanding  the  fact  that  the  disease 
is  often  secondary  to  cancer  of  the  uterus  and  breast,  (r)  Heredity. — 
This  is  regarded  by  some  authors  as  a  probable  cause  in  from  15  to  20 
per  cent  of  cases,  but  it  is  doubted  by  others.  (</)  Trauma. — In  some 
cases  there  is  a  history  of  direct  injury;  in  others  the  passage  of  gall- 
stones has  been  regarded  as  an  important  factor  in  the  production  of 
the  disease  in  either  the  liver  or  gall-bladder. 

Morbid  Anatomy. — Histologically,  the  growth  generally  belongs  to  the 
alveolar  or  trabecular  type,  rarely  to  the  cylindromata,  and  corresponds, 
as  a  rule,  to  that  of  the  primary  neoplasm, 

1 .  Of  the  primary  cancer  three  modes  of  growth  have  been  recognized  : 
(a)  The  massive,  one  or  a  few  large  masses  of  uniform  structure,  occupy- 
ing a  large  part  of  the  liver  substance  and  causing  decided  enlargement 
of  the  organ.  It  is  generally  white  or  gray  and  firm,  except  at  the  cen- 
ter of  the  medullary  variety.  (^)  The  nodular,  in  which  liver  tissue 
may  be  almost  completely  replaced  by  the  numerous  cancer  nodules 
of  different  sizes.  The  primary  nodule  can  generally  be  recognized  by 
its  greater  size  and  possibly  by  degeneration  at  the  center.  The  other 
nodules  are  secondary  to  it,  as  a  rule.  (<r)  Cancer  with  cirrhosis,  a 
rare  form  in  which  the  entire  liver  is  infiltrated  with  small,  yellowish 
gray  cancer  nodules  usually  not  more  than  0.5  cm.  in  diameter  and 
surrounded  by  fibrous  tissue.  The  liver  is  little,  if  at  all,  enlarged,  and 
its  surface  is  roughened,  much  as  in  cirrhosis. 

2.  Secondary  cancer  nodules  are  generally  multiple  and  so  large  as 
to  be  felt  on  palpation,  and  to  cause  great  enlargement  of  the  liver. 
In  color  and  consistence  they  resemble  the  primary  nodules,  but  more 
frequently  show  secondary  degeneration,  especially  hyalin  change,  in  the 
center,  and  they  may  be  umbilicated. 

Symptoms. — The  primary  disease  may  exist  for  a  considerable  time 
without  the  production  of  symptoms.  Cachexia  may,  in  fact,  be  the 
first  indication  of  the  disease,  or  this  may  be  preceded  by  pain  and 
jaundice,  with  occasional  elevation  of  temperature. 

The  symptoms  of  the  secondary  form  are  generally  preceded  by  those 
on  the  part  of  the  organ  primarily  affected,  especially  when  this  is  in 
the  stomach,  gall-bladder,  rectum,  or  other  part  of  the  alimentary  canal. 
The  usual  manifestations  are :  (a)  Emaciation  and  anemia,  which  are 
prominent  features  of  either  form.  The  red  corpuscles  may  be  fewer 
than   2,500,000,  and  leucocytosis  may  be  present  or  not.    The  tongue 


CANCER  OF  THE  LIVER  529 

usually  becomes  coated,  dry,  and  flat.  The  heart's  action  is  feeble.  (^) 
Evidences  of  obstruction  of  the  portal  circulation  develop.  The  super- 
ficial veins  become  distended,  ascites  and  edema  of  the  lower  extremities 
are  often  observed.  (^)  Jaundice  appears  in  about  half  the  cases  as 
a  result  of  compression  of  the  bile-passages.  The  skin  sometimes  be- 
comes mottled  with  a  brownish  discoloration;  sometimes  the  discolora- 
tion is  uniform  and  suggestive  of  Addison's  disease,  but  the  color  is 
generally  a  deeper  yellow.  (^)  Cachexia  develops  sooner  or  later  in 
all  cases.  The  skin  then  has  a  peculiar  and  characteristically  glossy 
pallor.  (^)  Fever  usually  appears  late  in  the  disease,  if  at  all.  It  may 
be  irregular,  intermittent,  and  only  moderate,  but  sometimes  toward 
the  close  it  runs  up  to  104°  or  105°  F.  (40.0° — 4o.5°C.).  In  some  in- 
stances it  is  of  a  septic  origin  and  type,  due  to  suppuration.  Occasion- 
ally the  temperature  becomes  subnormal  near  the  end  of  life,  (y)  Exami- 
nation of  the  abdomen  shows  enlargement,  particularly  in  the  upper 
portion,  except  in  the  sclerotic  form  of  cancer,  when  enlargement  may 
not  occur.  The  lower  margin  of  the  organ  can  be  distinctly  felt  several 
inches  below  the  margin  of  the  ribs,  and  the  nodules  can  be  readily 
palpated  in  many  cases ;  on  simple  inspection,  they  are  sometimes  recog- 
nizable through  the  abdominal  wall,  moving  with  the  diaphragm.  The 
liver  is  usually  sensitive.  The  duration  of  the  disease  from  the  time  of 
its  recognition  is  generally  from  three  to  eighteen  months,  rarely  longer. 

Diagnosis. — The  cardinal  symptoms  are  an  enlarged,  nodular,  sensi- 
tive liver,  with  pain,  progressive  emaciation  and  anemia,  jaundice,  loss 
of  strength,  and  cachexia.  The  chief  difficulty  lies  in  the  exclusion  of 
fatty  and  amyloid  liver,  hypertrophic  cirrhosis,  syphilis,  and  echinococcus. 

Fatty  and  amyloid  liver  are  eliminated  chiefly  by  the  pain,  marked 
jaundice,  cachexia,  more  rapid  emaciation,  and  the  nodular  surface. 

Hypertrophic  cirrhosis  is  attended  with  no  pain,  little  emaciation,  uni- 
form, less  rapid  enlargement  of  the  liver,  and  the  spleen  is  simultane- 
ously enlarged. 

Syphilitic  gummata  may  simulate  cancer  nodules  on  palpation,  but  the 
age  of  the  patient,  the  absence  of  cachexia,  and  the  results  of  a  judi- 
cious test  with  potassium  iodid  establish  their  identity. 

Echinococcus  is  of  less  rapid  growth,  the  nodules  are  softer,  and  there 
is  no  cachexia.  The  fluid  withdrawn  by  aspiration  establishes  the  diag- 
nosis. 

It  is  sometimes  difficult  to  distinguish  cancer  of  the  liver  from  that 
of  neighboring  organs,  and  the  differentiation  of  the  sclerotic  form  of 
the  disease  may  be  impossible. 

Treatment. — Measures  are  to  be  directed  to  the  support  of  strength 
and  relief  of  suffering.    There  is  no  curative  treatment. 


OTHER  TUMORS  OF  THE  LIVER. 

Sarcoma  rarely  attacks  the  liver  primarily,  and  it  is  by  no  means 
common  as  a  secondary  growth.  Nearly  all  the  varieties  have  been  en- 
countered secondarily,  especially  the  myxo-,  lympho-,  and  melanosar- 
comata.  The  last  is  a  part  of  a  universal  dissemination  following  the 
primary  growth  in  the  choroid  or  skin. 

34 


53  o  PR.\CTICE  OF  MEDICINE 

Angioma  is  a  not  infrequent  tumor  of  the  liver,  but  it  is  of  no  clinical 
interest.  Adenomata  and  cysts  are  occasionally  met  with.  The  latter 
are  usually  congenital  and  associated  with  cystic  disease  of  the  kidneys. 

PARASITES   OF  THE  LIVER. 

Echinococcus,  or  hydatid  cyst,  the  most  frequent  of  these,  is  con- 
sidered on  page  285.  Other  parasites  that  have  been  more  or  less  re- 
peatedly found  in  the  liver  are  the  lumbricoid  worms,  the  cysticercus 
cellulosae,  pentastomum  denticulatum,  the  distoma,  and  the  psoro- 
sperms. 

DISEASES    OF    THE    BILE-PASSAGES  AND 
GALL-BLADDER. 

JAUNDICE. 

ICTERUS. 

Definition. — A  condition  in  which  the  bile  pigment  becomes  disseminated 
throughout  the  body,  staining  the  skin,  mucous  membranes,  and  many 
other  tissues,  and  the  secretions.  Although  a  symptom,  rather  than  a 
disease,  the  condition  usually  receives  separate  consideration.  Two  forms 
are  recognized,  (i)  the  obstructive  and  the  (2)  nonobstructive  or  tox- 
emic. 

Etiology. — i.  Obstructive  Jaundice  is  produced  by  any  influence  within 
or  outside  of  the  liver,  which  causes  nearly  or  quite  complete  closure  of 
the  bile-ducts.  The  most  important  forms  of  obstruction  are :  (a)  Im- 
paction of  foreign  bodies,  especially  of  gall-stones,  concretions,  or  para- 
sites; (i^)  catarrhal  or  suppurative  inflammation  within  the  ducts  or 
at  the  orifice  of  the  common  duct,  or  strictures  resulting  from  such 
inflammation;  (t-)  tumors  within  the  ducts  or  causing  compression  of 
them.  Such  growths  include  neoplasms  not  only  of  the  gall-bladder, 
duodenum,  colon,  pancreas,  and  other  contiguous  structures,  but  occa- 
sionally those  of  the  kidneys,  uterus,  or  ovaries,  and  aneurisms  of  the 
aorta,  hepatic  or  mesenteric  arteries.  (^)  Fecal  impaction  is  a  possible 
cause. 

2.  Toxemic  jaundice  is  the  form  that  is  met  with  particularly  in  the 
acute  infections,  as  in  malaria,  yellow  fever,  acute  yellow  atrophy, 
typhus,  relapsing  fever,  Weil's  disease,  sometimes  in  typhoid  fever,  scar- 
latina, probably  also  in  some  cases  of  phosphorus,  arsenic,  ptomain,  and 
other  chemical  poisoning. 

Symptoms. — Obstructive    Jaundice i.    The    Skin  and   Conjunctiva. — 

(d!)  The  color  of  the  skin  varies  with  the  intensity  and  duration  of  the 
condition,  and  the  quantity  of  bile  pigment  deposited  in  it.  All  shades 
from  a  pale  lemon  yellow  to  a  greenish  brown  or  black  are  encountered 
in  different  cases.  They  are  usually  compared  to  lemon,  orange,  saffron, 
or  oHve.  The  color  is  seen  to  advantage  by  stretching  the  skin  across 
the  back  of  the  hand.  It  frequently  makes  its  first  appearance  in  the 
conjunctivae.  Qb^  Intense  pruritus  accompanies  the  jaundice,  the  itching 
being  most  severe  at  night.  This  may  precede  the  visible  manifestations. 
It  is  sometimes  confined  to  certain  regions,  as  the  palms  and  soles  or 
between  the  fingers  and  toes,     (r)  Sweating  is  commonly  observed,  and 


JAUNDICE  531 

it  also  is  sometimes  confined  to  certain  regions,  as  the  palms,  the  axillae, 
or  the  abdomen.  (^/)  Urticaria,  herpes,  xanthelasma,  furunculosis,  and 
carbuncles  sometimes  develop,  and  hemorrhages  into  either  the  skin  or 
mucous  membranes  are  occasionally  observed. 

2.  The  Secretions. — (rt;)  The  sweat,  saliva,  sometimes  the  bronchial 
mucus,  and  rarely  the  tears  are  stained  to  such  an  extent  that  they 
discolor  white  linen.  (JT)  The  urine  always  shows  the  presence  of  bile 
pigment  on  chemical  test,  if  not  in  its  color,  even  before  the  discolora- 
tion of  the  tissues  can  be  discerned.  When  the  jaundice  is  intense  or  of 
long  standing,  albumirt  is  generally  present,  and  the  microscope  reveals 
bile-stained  casts. 

3.  The  feces  are  of  a  pale  slate  or  gray  color,  owing  to  the  absence 
of  bile  pigment.  Constipation  and  flatulency  usually  exist,  and  the 
stools  are  pasty  and  offensive;  diarrhea  may  occasionally  supervene. 
Gastric  digestion  may  remain  normal. 

4.  Pulse  and  RespiratioTi. — The  pulse  is  generally  slow;  it  sometimes 
sinks  to  40  or  even  20  in  the  minute.  The  respiration  is  generally  nor- 
mal; it  may  be  reduced  in  ratio  to  the  pulse. 

5.  The  blood  is  often  normal  in  simple  catarrhal  jaundice,  except 
with  reference  to  its  corpuscles.  A  peculiar  enlargement  of  the  red  cells 
and  other,  unimportant,  changes  have  been  observed.  The  plasma  is 
stained  by  the  bile  pigment. 

6.  Hemorrhages  sometimes  occur  into  the  skin  or  from  the  mucous 
membranes  in  the  more  malignant  cases. 

7.  Cerebral  Symptoms. — Headache  and  vertigo  are  common,  and  the 
patient  often  becomes  irritable,  or  he  may  become  morose  and  melan- 
choly, with  mental  dullness,  somnolence,  or  restlessness  and  insomnia. 
A  fatal  stupor  sometimes  supervenes,  the  patient  dying  in  coma  or 
convulsions.  Such  symptoms  are  due  to  intoxication  of  unknown  char- 
acter, sometimes  spoken  of  as  cholemia.  The  vision  is  sometimes  dis- 
turbed. There  may  be  an  inability  to  see  distinctly  in  full  daylight 
(nyctalopia),  or  the  opposite  condition  (hemeralopia) ;  very  rarely 
objects  appear  yellow  (xanthopsia).  The  duration  of  icterus  is  exceed- 
ingly variable.  Acute  and  chronic  cases  occur.  The  former  usually 
recover  within  two  or  three  weeks ;  the  latter  may  last  for  several  years, 
with  or  without  intermissions.  Death  results  apparently  from  either 
exhaustion  or  toxemia. 

Diagnosis. — Jaundice  is  generally  self-evident,  except  in  the  dark- 
skinned  races.  From  the  discoloration  of  Addison's  disease  it  can  be  dis- 
tinguished by  the  presence  of  bile  pigments  in  the  urine. 

The  diagnosis  of  the  cause  is  important,  (a-)  When  the  gall-bladder 
is  distended  and  the  feces  are  colorless,  the  obstruction  is  usually  situ- 
ated at  the  duodenal  end  of  the  common  duct.  ((^)  Colorless  feces 
without  distention  of  the  gall-bladder  indicate  obstruction  of  the  hepatic 
duct.  When  neither  of  these  conditions  is  present,  the  obstruction  usu- 
ally affects  only  a  part  of  the  bile-ducts  within  the  liver.  (^)  Attacks 
of  severe  pain  in  the  region  of  the  gall-bladder  generally  point  to  gall- 
stones as  the  cause  of  the  obstruction.  (^)  When  fever  is  present,  it  is, 
as  a  rule,  due  to  catarrhal  inflammation  involving  the  smaller  ducts 
within  the  liver.  (^)  A  moderate,  chronic  jaundice  is  usually  due  to 
cirrhosis,   malignant  disease,   or  chronic  passive  hyperemia.     The  first 


532 


PRACTICE  OF  MEDICINE 


of  these  conditions  is  rendered  probable  by  the  coexistence  of  ascites, 
the  second  by  enlargement  and  a  nodular  surface  of  the  liver,  and  the 
third  by  a  valvular  lesion  of  the  heart. 

Prognosis. — This  depends  entirely  upon  the  cause  of  the  condition. 
Catarrhal  jaundice  usually  subsides  within  a  few  weeks;  persistent, 
deep,  and  increasing  icterus  is  more  generally  associated  with  a  fatal 
disease. 

Treatment.— The  treatment  is  that  of  acute  or  chronic  angiocholitis 
and  the  other  affections  causing  the  condition. 

Toxemic  Jaundice. — The  symptoms  of  this  condition  are  not  usually 
so  pronounced  as  those  of  the  obstructive  form.  In  the  acute  infections, 
as  malaria,  the  skin  acquires  only  a  pale  tinge ;  the  feces  are  bile-stained, 
and  the  urine  may  contain  little  or  no  bile  pigment,  although  it  is  deeply 
colored  with  other  pigments.  In  the  more  mahgnant  forms,  as  in  acute 
yellow  atrophy,  the  color  becomes  intense.  The  constitutional  disturb- 
ances are  profound,  being  often  manifested  by  high  temperature,  deli- 
rium, convulsions,  black  vomit,  suppression  of  urine  and  cutaneous 
hemorrhages  as  seen  particularly  in  yellow  fever. 

The  treatment  is  that  of  the  disease  of  which  the  jaundice  is  a 
symptom. 

ICTERUS  NEONATORUM. 

Defin/'t/'on.—^'  Jaundice  of  the  new-born  infant."  Two  forms  of  the  con- 
dition are  recognized,  a  mild  form,  sometimes  referred  to  as  physiologi- 
cal icterus,  which  is  never  fatal;  and  a  severe,  generally  fatal,  form. 

Etiology.— Various  theories  have  been  offered  in  explanation  of  the  con- 
dition. The  mild  form  is  generally  attributed  to  stasis  of  the  bile  within 
the  tubules  as  a  result  of  its  abnormal  concentration,  feeble  respiration 
and  circulation,  or  from  compression  of  the  bile  capillaries  by  distended 
portal  vessels.  It  has  been  referred  to  the  rapid  destruction  of  blood- 
corpuscles  during  the  first  days  after  birth  and  to  other  conditions  not 
yet  demonstrated. 

The  causes  generally  discovered  in  the  severe  form  are  a  congenital 
occlusion  of  the  common  bile-duct,  congenital  syphilitic  cirrhosis,  or  pyle- 
phlebitis due  to  septic  infection  through  the  umbilical  vein. 

Symptoms.— Mild  cases  generally  begin  within  the  first  three  days, 
present  the  usual  symptoms  of  jaundice— discoloration  of  the  skin,  sclerae 
and  urine  and  chalky  feces— and  subside  within  a  week  or  two.  Severe 
cases  present,  in  addition  to  these  manifestations,  an  elevation  of  tem- 
perature and  sometimes  the  symptoms  of  severe  sepsis— fever,  vomiting, 
and  profound  prostration.  Persistent  hemorrhage  from  the  cord  some- 
times occurs.    These  cases  are  rapidly  fatal. 

Treatment  of  the  mild  cases  is  unnecessary ;  treatment  of  the  severe 
cases  is  futile, 

ANGIOCHOLITIS, 

CHOLANGITIS. 

Z7e^/7/V/o/j,— Inflammation  of  the  bile-ducts.  The  disease  may  be  sim- 
ple catarrhal,  infectious,  suppurative,  or  ulcerative.  Diphtheritic  or 
croupous  and  hemorrhagic  inflammations  have  been  described,  but  they 
cannot  be  differentiated  clinically. 


ANGIOCHOLITIS  533 

CATARRHAL  ANGIOCHOLITIS. 

This  form  of  the  disease  may  be  either  acute  or  chronic. 

I.  Acute  Catarrhal  Angiocholitis.— An  acute  inflammation  of  the 
common  bile-duct,  causing  obstruction  and  consequent  icterus. 

Etiology. — (^a)  The  disease  is  most  frequent  in  young  persons,  but 
it  may  occur  at  any  age.  It  is  generally,  if  not  always,  an  extension  of 
inflammation  from  the  duodenum.  This  in  turn  results  from  a  catarrhal 
condition  of  the  stomach,  arising  from  the  ingestion  of  irritating  sub- 
stances taken  as  food  or  drink,  or  from  irritant  medicines  or  poisons. 
By  some  writers  it  is  regarded  as  invariably  of  infectious  nature.  (^) 
It  is  sometimes  attributed  to  exposure  to  cold,  and  it  may  often  be 
traced  to  the  active  or  passive  congestion  of  cirrhosis,  or  disease  of  the 
heart  or  kidneys,  (r)  It  sometimes  complicates  the  acute  infections, 
particularly  pneumonia,  typhoid  fever,  or  malaria.  (^)  It  may  occur 
as  an  epidemic,  or  (^)  follow  emotional  disturbances. 

Morbid  Anatomy. — The  inflammation  is  generally  limited  to  the  du-" 
odenal  end  of  the  common  duct,  particularly  to  the  portion  within  the 
intestine  (portio  intestinalis) ;  it  is  thought  in  some  cases  to  extend 
back  to  the  intrahepatic  or  to  the  cystic  ducts  and  gall-bladder,  but, 
as  the  disease  is  not  a  fatal  one,  post-mortem  observations  have  been 
too  few  to  establish  the  truth  of  the  supposition.  The  duct  is  usually 
obstructed  with  a  plug  of  tenacious,  bile-stained  mucus,  sometimes 
limited  to  the  intestinal  portion,  without  definite  evidences  of  the  ex- 
tent of  the  inflammation  that  existed  before  death.  The  liver  is  usu- 
ally enlarged  and  the  gall-bladder  distended.  Gall-stones  are  sometimes 
present,  but  this  condition  is  considered  separately  in  the  succeeding 
section. 

5/m/j/o/ws.— Jaundice  is  usually  the  first  symptom  indicative  of  the 
condition.  It  may  appear  as  the  first  evidence  of  illness,  or  it  may  be 
preceded  for  a  week  or  longer  by  more  or  less  severe  gastrointestinal 
disorder,  gastrointestinal  catarrh,  or  catarrhal  enteritis,  with  discomfort, 
pain,  and  tenderness  in  the  region  of  the  liver,  the  pain  often  radiating 
to  the  back  and  shoulder  or  to  the  limbs.  Constitutional  symptoms 
are  generally  present  and  may  assume  considerable  severity.  Nausea 
and  vomiting,  headache,  malaise,  and  moderate  fever  are  often  com- 
plained of.  The  usual  signs  of  obstructive  jaundice  also  appear,  as  the 
discoloration  of  the  skin,  tissues,  and  urine,  with  clay -colored  stools, 
perhaps  with  restlessness  and  pruritus,  but  the  skin  is  not  so  intensely 
bronzed  as  in  chronic  obstruction.  The  pulse  and  respiration  may  be 
reduced  in  rate.  Slight  enlargement  of  the  liver  and  spleen  can  gener- 
ally be  made  out,  but  the  gall-bladder  cannot  usually  be  felt.  The 
duration  of  the  disease  is  from  two  weeks  to  three  months,  in  most 
cases  about  a  month. 

Diagnosis. — The  recognition  of  this  disease  is  not  difficult  in  a  young 
person.  When,  however,  in  middle  life,  the  jaundice  persists  beyond  the 
usual  four  or  six  weeks,  a  fear  of  a  more  serious  afl'ection,  as  cancer 
or  gall-stones,  is  aroused.  Such  affections  are  excluded,  for  the  most 
part,  through  the  absence  of  pain  and  other  diagnostic  symptoms. 

Prognosis.— ^\m^\e  angiocholitis  is  never  fatal.  The  first  indication 
of  recovery  is  a  return  of  color  to  the  feces. 

Treatment— In  mild  cases  little  treatment  is  required  further  than  the 


534  PRACTICE  OF  MEDICINE 

regulation  of  the  bowels  and  restriction  of  the  diet  until  the  catarrhal 
condition  has  had  time  to  subside.  Small  laxative  doses  of  calomel 
may  be  given  every  second  or  third  day  in  the  beginning,  and  follov/ed 
by  a  saline  laxative,  as  sodium  phosphate,  on  the  succeeding  morning. 
Purgation  is  to  be  avoided.  Large  quantities  of  water  should  be  drunk, 
preferably  alkaline  mineral  waters  or  water  containing  a  little  sodium 
bicarbonate.  Or  the  salicylate  may  be  given  in  small  doses  and  the  water 
taken  pure.  Daily  irrigation  of  the  large  bowel  with  cold  water  has 
been  recommended.  The  diet  should  be  limited  in  quantity,  and  such 
articles  as  will  throw  the  least  work  upon  the  liver— meat,  fats,  and 
sweets,  being  excluded.  It  is  necessary  to  confine  the  patient  to  bed  only 
when  fever  is  present  or  when  the  pulse-rate  is  greatly  reduced. 

2.  Chronic  Catarrhal  Angiocholitis  (Hepatic  Fever,  Chronic  Cholan- 
gitis).— Etiology. — The  common,  if  not  the  exclusive,  cause  of  this  form 
of  the  disease  is  obstruction  of  the  common  bile-duct,  whether  by  gall- 
stones, stricture,  neoplasm,  or  pressure,  causes  which  have  been  referred 
to  elsewhere  under  the  heads  of ''jaundice"  and  "gall-stones."  It  some- 
times, perhaps,  follows  repeated  attacks  of  acute  angiocholitis. 

Morbid  Anatomy. — The  walls  of  the  common  duct  are  thickened.  Its 
mucous  membrane  may  be  little  altered  or  it  may  show  the  usual 
changes  of  chronic  inflammation.  The  duct  is  distended  to  a  degree 
corresponding  to  the  extent  of  the  obstruction.  When  the  obstruction 
is  complete,  all  the  bile-passages  and  the  gall-bladder  are  greatly  dis- 
tended and  filled  with  a  clear,  usually  sterile  mucus.  When  the  obstruc- 
tion is  but  partial,  the  mucus  is  turbid  and  bile-stained.  In  the  ma- 
jority of  cases,  gall-stones  are  found  in  the  gall-bladder  or  common  duct 
or  in  both;  but  in  some  cases,  although  gall-stones  have  been  passed 
during  life,  they  are  not  found  within  the  passages. 

Symptoms. — The  usual  symptoms  of  obstruction  are  present,  particu- 
larly icterus,  staining  of  the  urine  and  other  secretions  and  colorless 
feces,  but  a  more  distinctive  feature  is  the  periodical  occurrence  of  the 
intermittent  tvpe  of  fever,  which  has  received  the  name  of  hepatic  in- 
termittent fever.  This  is  characterized  by  an  attack  of  chill,  fever,  and 
sweating,  with  prostration,  sometimes  pain,  lasting  for  a  few  days  and 
recurring  at  intervals  of  a  few  weeks  or  months.  The  cause  is  not  defi- 
nitely known,  but  it  is  thought  to  be  infection  or  aggravation  of  the 
previous  inflammation  by  the  passage  of  calculi.  The  attack  is  not  neces- 
sarily indicative  of  suppuration. 

3.  Suppurative  and  Ulcerative  Angiocholitis.— A  diff"use,  suppurative 
inflammation  of  the  larger  and  smaller  bile-ducts  usually  associated 
with  similar  disease  of  the  gall-bladder. 

Etiology. — The  direct  cause  is  infection.  The  mucous  membrane  is 
rendered  liable  to  infection  through  direct  injury,  particularly  through 
the  extension  of  inflammation  from  an  adjacent  focus,  as  from  a  p\'le- 
phlebitis,  an  abscess,  or  malignant  disease  in  the  liver.  Extension  from 
the  gall-bladder  is  not  common,  but  it  may  occur.  Many  cases  have  fol- 
lowed typhoid  fever  or  pneumonia,  and  the  pneumococcus,  typhoid,  and 
colon  bacilli,  streptococci,  and  staphylococci  have  been  found  in  the  pus. 

Morbid  Anatomy. — All  the  ducts  are  thickened  and  distended  with  pus 
and  bile,  sometimes  mingled  with  mucus  and  blood.  Here  and  there  the 
walls    show    saccular  dilatations,   which  are  virtually  abscess  cavities, 


ACUTE  INFECTIOUS  CHOLECYSTITIS  535 

and  the  mucous  membrane  is  often  ulcerated  or  necrotic,  especially  in 
cases  arising  from  gall-stones.  The  gall-bladder  is  usually  affected,  its 
walls  thickened  and  distended  with  pus,  ulcerated  and  adherent  to  sur- 
rounding viscera,  sometimes  perforated. 

Symptoms. — The  symptoms  are  those  of  profound  septic  inflammation 
with  marked  enlargement  and  sensitiveness  of  the  liver  and  gall-bladder. 
Pain  may  or  may  not  be  a  prominent  feature,  and  jaundice,  although 
constant,  may  be  slight  or  profound.  Leucocytosis  is  usually  present. 
The  patient  becomes  weak  and  emaciated. 

ACUTE    INFECTIOUS   CHOLECYSTITIS. 

Definition. — An  acute  inflammation  of  the  gall-bladder  due  to  the  en- 
trance of  bacteria. 

Etiology. — The  specific  cause  is  bacterial  invasion.  Infection  is  fa- 
vored by  the  presence  of  gall-stones  or  of  a  foreign  body,  but  it  may 
occur  independently  of  all  such  local  conditions.  In  some  instances  the 
disease  has  been  regarded  as  an  extension  of  inflammation  from  the 
common  duct  or  elsewhere  in  the  vicinity,  and  it  often  follows  an  acute 
infection,  particularly  pneumonia  or  typhoid  fever. 

Morbid  Anatomy. — There  are  three  types  of  the  disease,  the  catarrhal, 
the  suppurative,  and  the  phlegmonous,  and  the  condition  found  after 
death  corresponds  to  one  of  these  types,  usually  to  the  suppurative  or 
phegmonous.  The  gall-bladder  is  distended  and  its  walls  are  tense. 
There  may  be  adhesions  to  other  organs,  localized  abscesses  or  perfora- 
tion with  discharge  of  the  contents,  and  with  the  production,  in  the 
more  violent  cases,  of  a  general  peritonitis.  The  contents  of  the  gall- 
bladder are  mucopurulent,  purulent,  or  hemorrhagic,  often  foul  in  odor 
and  containing  various  bacteria.  The  pneumococcus,  typhoid  bacillus, 
streptococci,  and  staphylococci  are  commonly  found.  The  cystic  duct 
is  usually  closed,  whether  or  not  calculi  be  present. 

Symptoms. — The  symptoms  are  not  distinctive.  There  is  usually  pain 
in  the  region  of  the  liver,  sometimes  it  is  in  the  epigastrium  or  elsewhere 
in  the  abdomen,  even  at  a  point  suggesting  appendicitis.  Fever  develops, 
the  pulse  becomes  rapid,  nausea  and  vomiting  follow,  and  the  abdomen 
becomes  distended  and  tender,  the  tenderness  finally  becoming  local- 
ized, in  most  cases,  in  the  region  of  the  distended  gall-bladder.  Jaun- 
dice develops  when  gall-stones  are  present,  but  not,  as  a  rule,  when  they 
are  absent.  The  gall-bladder  cannot  always  be  felt.  More  or  less  com- 
plete obstruction  of  the  bowel  sometimes  occurs,  even  gas  failing  to  pass 
in  extreme  cases,  probably  as  a  result  of  adhesions  between  the  gall- 
bladder and  bowel. 

The  diagnosis  is  often  extremely  difficult  on  account  of  the  uncertainty 
of  the  symptoms,  particularly  the  uncertain  location  of  the  pain  and 
tenderness  which  may  lead  to  the  erroneous  diagnosis  of  appendicitis 
or  intestinal  obstruction.  The  diagnosis  of  the  type  of  the  inflammation 
is  impossible.  The  presence  of  jaundice  is  of  value,  but  it  is  unfortu- 
nately absent  in  many  cases.  When  vague  symptoms  of  the  character 
just  described  follow  an  acute  infection,  particularly  typhoid  fever  or 
pneumonia,  the  possibility  of  an  acute  cholecystitis  should  be  borne  in 
mind. 


536  PRACTICE  OF  MEDICINE 

Prognosis. — The  disease  is  exceedingly  fatal,  unless  it  be  early  relieved 
through  surgical  measures. 

Treatment. — The  treatment  is  entirely  surgical. 

CHOLELITHIASIS. 

pALL-STONES,  BILIARY  CALCULI,   OR  CONCRETIONS. 

Definition. — A  condition  in  which  concretions,  "gall-stones,"  are  formed 
within  the  bile-ducts  or  gall-bladder. 

Etiology. — More  than  half  the  cases  occur  in  persons  above  40  years 
of  age,  rarely  in  those  under  25,  but  congenital  cases  have  been  recorded. 
Fully  75  per  cent  of  cases  occur  in  women,  90  per  cent  of  whom  have 
borne  children.  Chief  among  the  predisposing  causes  are  conditions 
believed  to  favor  the  stagnation  of  bile,  overindulgence  in  food,  seden- 
tary or  indolent  habits,  occupations  which  require  a  leaning  attitude, 
constipation,  corset-wearing,  enteroptosis,  and  nephroptosis.  The  imme- 
diate formation  of  gall-stones  consists  in  the  deposit  of  cholesterin, 
lime,  or  other  salts  from  the  bile  upon  a  nucleus.  The  nucleus  is  gener- 
ally composed  of  epithelial  debris  and  micro-organisms,  occasionally 
of  bile-salts;  rarely  it  is  a  foreign  body.  It  is  probable  that  the  micro- 
organisms are  the  important  element  in  most  cases,  for  gall-stones  have 
been  experimentally  produced  by  inoculation  of  the  gall-bladder  of 
animals  with  attenuated  cultures  of  the  colon  and  typhoid  bacilli.  These 
organisms  are  repeatedly  found  in  the  gall-bladder  and  they  are  capable 
of  living  there  for  a  great  length  of  time.  The  so-called  lithogenous 
catarrh,  which  has  long  been  regarded  as  the  essential  factor  in  the  pro- 
duction of  concretions,  is  induced  by  the  bacteria.  It  is  believed  to  so 
modify  the  mucous  membrane  of  the  gall-bladder  and  ducts  that  they 
secrete,  as  shown  by  Naunyn,  both  cholesterin  and  calcium,  the  most 
important  ingredients  of  the  calculi. 

Physical  Properties  of  Gall-Stones. — A  single  gall-stone  sometimes  at- 
tains an  enormous  size,  as  much  as  five  inches  in  length  and  distending 
the  gall-bladder.  As  a  rule,  however,  there  are  several  smaller  concre- 
tions more  or  less  completely  filling  the  viscus.  More  than  a  thousand 
calculi  may  be  found  in  it,  and  the  bile-ducts  within  the  liver  some- 
times contain  enormous  numbers  of  them.  When  a  moderate  number 
of  stones  of  medium  size  are  contained  in  the  gall-bladder,  they  usually 
have  four  or  more  facets  and  often  resemble  beech-nuts,  or  they  may  be 
irregular  or  rough  like  mulberries.  They  may  be  so  minute  as  to  be 
rightly  designated  sand.  In  composition  the  larger  stones  often  consist 
chiefly  of  cholesterin,  some  containing  98  per  cent,  in  an  amorphous  or 
crystalline  form.  When  cut,  the  crystalHne  stones  show  both  radiating 
and  concentric  striations.  Others,  particularly  the  smaller  ones,  contain 
the  salts  of  lime,  magnesia,  bile  acids,  fatty  acids,  and  sometim/js  traces 
of  iron  and  copper.  Those  containing  much  cholesterin  are  lustrous  and 
on  section  are  of  almost  pure  white  color ;  others  present  various  colors, 
often  beautiful  striations,  and  have  usually  a  hard  external  crust  of  a 
yellow,  gray,  brownish,  or  almost  black  color.  The  nucleus  is  generally 
visible.  Calculi  generally  lodge  at  the  duodenal  end  of  the  common 
duct,  frequently  in  the  intestinal  portion,  sometimes  in  the  cystic  duct 
or  at  the  orifice  of  the  gall-bladder. 


CHOLELITHIASIS  537 

Symptoms. — One  or  many  calculi  may  remain  in  the  gall-bladder 
indefinitely  without  giving  rise  to  symptoms.  It  is  estimated  that 
fully  25  per  cent  of  all  women  over  60  are  the  subjects  of  gall-stone, 
yet  only  a  small  minority  of  them  suffer.  The  more  serious  results  are, 
therefore,  to  be  regarded  as  in  the  nature  of  accidents.  These  are  gener- 
ally considered  under  three  heads:  (i)  Biliary  colic,  a  result  of  the 
passage  of  a  stone  through  the  ducts;  (2)  chronic  obstruction,  a  result 
of  permanent  plugging  of  the  cystic  or  hepatic  duct;  and  (3)  remote 
effects,  notably  ulceration,  perforation,  or  the  formation  of  fistulae. 

I.  Biliary  Colic. — The  passage  of  a  gall-stone  through  the  cystic  or 
hepatic  duct  is  not  invariably  painful,  but  in  a  majority  of  cases  that 
come  under  observation  it  is  extremely  so.  The  attack  often  follows 
a  sudden  jar,  a  fall  or  jump,  but  it  may  occur  spontaneously  at  night. 
The  patient  is  suddenly  seized  with  an  excruciating,  lancinating  pain  in 
the  right  hypogastrium,  epigastrium,  or  lower  thoracic  region,  which 
often  radiates  to  the  right  shoulder.  It  is  so  intense  that  he  rolls  from 
side  to  side  or  assumes  cramped-up  positions  in  efforts  to  obtain  relief. 
The  pain  is  due  to  the  passage  of  the  stone  through  the  cystic  duct, 
the  inflammation  occasioned  by  it,  or  to  the  distention  of  the  gall- 
bladder by  the  pent-up  fluid.  It  is  at  first  paroxysmal,  but  may  be- 
come continuous.  The  attack,  after  lasting  from  a  few  hours  to  a  week 
or  longer,  ceases  suddenly.  Intervals  of  complete  cessation  of  pain  are 
not  unusual.  Chills,  with  fever  and  vomiting,  usually  occur  soon  after 
the  onset.  The  vomit  may  contain  bile  if  the  obstruction  be  not  com- 
plete. The  patient  sometimes  becomes  greatly  prostrated  or  sinks  into 
a  collapse,  with  pinched  features,  cold  extremities,  cyanosis,  cold  sweat- 
ing, and  restlessness,  even  under  morphin.  Hiccough  may  develop  and 
convulsions  may  occur.  Jaundice  generally  appears  if  the  attack  lasts 
more  than  a  day  or  two.  The  abdomen  becomes  distended  and  sensi- 
tive, particularly  in  the  region  of  the  liver  and  gall-bladder.  The  stools 
are  pale,  and  the  urine  often  contains,  in  addition  to  bile,  albumin  or 
blood.  Any  of  these  symptoms  may  be  intermittent.  The  course  of  the 
disease  is  indefinite.  It  may  terminate  in  a  few  hours  or  days  and  per- 
manently with  the  first  attack,  or  it  may  recur  at  various  intervals  for 
years.  The  results  are  equally  uncertain.  Impaction  may  occur,  with 
the  production  of  chronic  jaundice,  if  the  impaction  is  in  the  common 
duct.  There  is  then  great  danger  of  angiochohtis  and  its  results,  perfo- 
ration, with  fatal  syncope  or  subsequent  fatal  peritonitis.  Disturbance  of 
a  previously  diseased  heart  is  sometimes  the  immediate  cause  of  death. 

Diagnosis. — The  sudden  onset  of  intense  pain,  followed  by  vomiting 
and  prostration,  with  tenderness  in  the  region  of  the  gall-bladder,  are 
generally  sufficient  for  a  diagnosis,  particularly  when  jaundice  develops. 
The  affections  to  be  excluded  are  gastralgia,  gastric  or  duodenal  ulcer, 
nephritic  colic,  and  appendicitis. 

Gastralgia  is  generally  accompanied  with  such  evidences  of  a  disordered 
stomach  as  flatulency  or  superacidity,  and  temporary  relief  is  afforded 
by  pressure  or  eructation. 

Gastric  and  duodenal  ulcers  are  attended  with  hematemesis  or  melena, 
the  former  immediately,  the  latter  two  or  three  hours,  after  a  meal. 

The  pain  of  nephritic  colic  radiates  to  the  groin  or  thigh,  and  the 
urine  generally  contains  blood.    A  calculus  may  be  passed. 


538  ^  PRACTICE  OF  MEDICINE 

Appendicitis. — It  is  only  when  the  appendix  occupies  a  high  position  that 
it  may  cause  confusion.  A  differentiation  may  then  be  impossible  without 
incision,  unless  jaundice  appear  or  stones  can  be  found  in  the  stools. 

2.  Chronic  Obstruction. — The  obstruction  may  occur  in  the  cystic  or 
common  duct,  and  the  symptoms  differ  accordingly. 

Chronic  obstruction  of  the  cystic  duct  leads  to  :  (^a)  Dilatation  of  the 
gall-bladder.  For  a  time  the  contents  consist  of  mucus  or  mucopuru- 
lent fluid  and  bile,  but  later  they  become  clear,  of  low  specific  gravity 
and  alkaline  or  neutral  reaction.  Albumin  also  is  usually  found.  The 
condition  has  been  called  dropsy  of  the  gall-bladder  (hydrops  vesicae 
felleae).  More  than  a  quart  of  fluid  may  be  present.  The  outline  of  the 
viscus  and  its  connection  with  the  liver  can  generally  be  recognized  by 
palpation  and  percussion,  sometimes  on  inspection.  Jaundice  is  often 
absent.  A  peculiar  gall-stone  crepitus  can  sometimes  be  felt  through 
the  thin,  relaxed  abdominal  wall,  if  the  bladder  be  not  too  tense. 

(J)^  Acute  cholecystitis  sometimes  develops,  and  it  may  become  sup- 
purative, although  it  is  generally  simple  in  the  beginning.  Perforation 
may  follow.  When  the  gall-bladder  is  distended  with  pus  the  condition 
is  termed  an  empyema  of  the  gall-bladder. 

(<:)  Calcification  of  the  gall-bladder  is  an  occasional,  late  result 
of  distention.  The  walls  become  infiltrated  with  lime-salts  and  the 
mucous  membrane  incrusted.  The  term  ossification  has  been  improperly 
applied  to  the  condition. 

(</)  Atrophy  sometimes  follows,  the  fluid  disappearing,  and  the  walls 
shrinking  into  a  small  nodule,  often  containing  a  small  calculus. 

Obstruction  of  the  common  duct  may  be  complete  or  partial.  It  may 
be  occasioned  by  the  lodgment  of  one  or  many  stones  in  any  part  of 
the  duct.  A  peculiar  form  is  that  in  which  one  stone,  lodged  in  the 
intestinal  portion  of  the  common  duct,  or  higher  up,  acts  as  a  ball- 
valve.  With  complete  obstruction,  the  hepatic  ducts  become  greatly 
distended  and  the  intense  jaundice  persists.  The  fluid  within  them  may 
become  clear  and  remain  sterile.  The  symptoms  are  often  intermittent, 
with  recurrent  attacks  of  jaundice,  and  the  stools  becoming  alternately 
light  and  dark.  Symptoms  may  be  absent;  the  liver  and  gall-bladder 
may  remain  nearly  or  quite  normal  in  size.  An  infectious  cholangitis 
is  often  set  up,  however,  which  is  recognizable  by  the  usual  symptoms, 
particularly  by  the  hepatic  enlargement  and  tenderness,  with  fever. 
Osier  attributes  the  repeated  attacks  of  so-called  hepatic  intermittent 
fever,  sometimes  recurring  for  years  without  evidence  of  suppuration, 
to  the  action  of  the  ball-valve  calculus.  Suppurative  cholangitis  may, 
however,  supervene. 

3.  Remote  Effects  of  Gail-Stones.— The  most  important  of  these  are 
the  development  of  biliary  fistulae  and  intestinal  obstruction,  (a)  Fis- 
tulous communication  has  been  established  between  the  gall-bladder 
and  the  hepatic  duct,  the  peritoneal  cavity,  or  a  cavity  formed  in  the 
liver.  In  several  instances  the  portal  vein  was  opened.  Communications 
with  parts  of  the  gastrointestinal  tract  are  common,  particularly  with 
the  duodenum  or  colon,  seldom  with  the  stomach.  Gall-stones  have 
been  found  in  the  urinary  bladder  as  a  result  of  fistulous  communication, 
and  they  have  been  coughed  up  through  openings  into  the  lung.  They 
have  escaped,  also,  through  cutaneous  fistulse. 


HEMORRHAGE  OF  THE  PANCREAS  539 

(^)  Intestinal  obstruction  by  gall-stones  is  not  an  extremely  infre- 
quent accident.  A  large  number  of  stones  are  often  passed  without 
its  occurrence,  and  in  a  majority  of  cases  the  stones  causing  obstruction 
have  been  lodged  in  a  diverticulum  or  in  the  appendix. 

Treatment  of  Gall-Stones. — An  attack  of  hepatic  colic  calls  for  the 
prompt  administration  of  morphin  hypodermically  in  doses  of  %  grain 
(0.016),  repeated  with  caution.  A  few  inhalations  of  chloroform  may 
be  administered  until  the  morphin  has  taken  effect.  Hot  fomentations 
should  be  applied  freely.  The  remedies  most  in  favor  for  their  supposed 
action  in  preventing  gall-stone  formation  or  in  dissolving  them  when 
formed  are  sodium  salicylate  and  olive  oil,  and  Durande's  mixture  of 
ether  and  turpentine.  The  sodium  salicylate  should  be  given  in  the  quan- 
tity of  gr.  xxx  or  more  daily,  and  olive  oil  in  tablespoonful  doses, 
or  more,  three  times  a  day.  Both  may  be  coincidently  employed  with 
excellent  results.  Fatty  concretions  are  often  formed  from  the  oil  and 
may  be  mistaken  for  gall-stones.  The  itching  is  to  some  extent  relieved 
by  dusting  the  skin  with  starch-powder  containing  camphor,  or  by 
inunction  with  carbolated  vaselin.  The  patient  should  take  outdoor 
exercise  and  restrict  his  diet  largely  to  fresh  vegetables  and  fruits,  ex- 
cluding meats  and  fats.  The  advisability  of  surgical  measures  should 
not  be  overlooked  in  the  case  of  a  person  whose  age  and  strength  jus- 
tify an  operation. 

CANCER  OF  THE  GALL-BLADDER  AND  BILE-DUCTS. 

Etiology. — The  disease  may  be  primary  or  secondary.  Both  are  pecu- 
liar to  the  cancer  age.  The  former  affects  the  sexes  about  equally; 
the  latter  is  about  three  times  more  frequent  in  women.  The  presence 
of  gall-stones  is  thought  to  greatly  favor  the  development  of  the  dis- 
ease. 

Morbid  Anatomy. — The  growth  begins  in  the  fundus  of  the  gall-bladder 
or  in  the  common  bile-duct,  usually  near  its  junction  with  the  duo- 
denum. 

Symptoms.— Vain  and  tenderness  in  the  region  of  the  gall-bladder, 
followed  by  jaundice  and  the  formation  of  a  tumor,  with  the  development 
of  a  cachexia,  are  the  usual  symptoms.  Distention  of  the  gall-bladder, 
and  jaundice,  are  more  certain  when  the  duct  is  affected. 

Diagnosis. — The  chief  elements  in  the  diagnosis  are  the  presence  of  a 
solid  tumor,  jaundice,  and  cachexia.  The  diagnosis  is  not  difficult,  as  a 
rule,  when  a  primary  growth  can  be  discovered  in  some  other  region. 

Treatment. — Unless  the  case  can  be  treated  surgically,  only  palliative 
measures  can  be  employed. 

DISEASES    OF    THE    PANCREAS. 

HEMORRHAGE  OF  THE  PANCREAS. 

Etiology. — Pancreatic  hemorrhage  has  usually  occurred  in  individuals 
above  40  and  more  frequently  in  men.  Very  little  is  positively  known 
of  the  cause.  The  accidents  and  conditions  generally  inducing  it  are : 
(a)  Blows  and  penetrating  wounds;  ((^)  acute  pancreatitis;  (r)  chronic 
passive  congestion  from  cardiac  valvular  disease  or  portal  obstruction ; 


540  PRACTICE  OF  MEDICINE 

(/^)  abnormal  blood-states,  as  in  purpura,  scurvy,  pernicious  anemia, 
or  the  acute  infections;  (^)  diseases  of  the  blood-vessels,  as  arterio- 
sclerosis, embolism,  or  aneurism;  and  (y)  fat-necrosis,  cystic  degener- 
ation, or  cancer  of  the  gland. 

Morbid  Anatomy. — The  hemorrhage  may  be  circumscribed  and  the 
degenerative  changes  causing  or  resulting  from  it  may  be  confined  to 
one  or  more  areas,  but  in  many  cases  the  entire  gland  is  more  or  less 
completely  destroyed  or  degenerated,  and  the  degeneration  may  even 
affect  adjacent  tissues. 

Symptoms. — The  individual  is  usually  seized  suddenly  with  the  most 
intense  pain  in  the  region  of  the  pancreas.  This  is  followed  by  marked 
prostration  or  complete  collapse.  The  temperature  becomes  subnormal, 
the  pulse  feeble;  the  body  is  bathed  in  a  cold  sweat,  and  great  restless- 
ness develops.  Nausea  and  vomiting  usually  accompany  the  seizure. 
Tenderness  is  generally  found  in  the  epigastrium  or  just  below  it.  Death 
often  occurs  in  syncope  or  coma,  as  a  result  of  pressure  and  reflex 
paralysis  of  the  heart,  rather  than  from  the  loss  of  blood.  If  death  be 
delayed  for  a  few  days,  fever  develops  and  the  abdomen  becomes  tym- 
panitic; the  bowels  are  usually  constipated. 

Diagnosis. — The  recognition  of  the  disease  is  based  upon  the  sudden- 
ness of  the  onset  and  the  location  of  the  pain  and  tenderness.  From 
the  collapse  following  the  perforation  of  a  gastric  or  intestinal  ulcer 
it  is  generally  differentiated  by  the  previous  healthy  condition  of  the 
patient.  The  diagnosis  is  not  always  possible,  and  the  condition  has 
repeatedly  been  discovered  post  mortem. 

Prognosis. — The  prognosis  is  extremely  unfavorable,  but  recovery  is 
believed  to  have  occurred. 

Treatment. — Morphin  and  hot  fomentations  or  an  ice-bag  are  required 
for  the  relief  of  the  pain.  The  ad\  isability  of  surgical  treatment  should 
be  immediately  determined. 

ACUTE  PANCREATITIS. 

1.  Acute  Hemorrhagic  Pancreatitis.— This  form  of  the  disease  is  not 
clearly  distinguished  from  hemorrhage  of  the  pancreas,  and  it  is  often 
impossible  in  a  given  case  to  determine  whether  the  inflammation  or 
the  hemorrhage  was  the  initial  lesion. 

Etiology. — The  disease  is  generally  encountered  in  adult  males,  often 
in  those  addicted  to  alcoholism.  The  immediate  cause  is  probably  an 
extension  of  inflammation  from  the  duodenum,  occasionally,  perhaps, 
the  passage  of  bile  into  the  pancreatic  duct,  since  the  disease  has  been 
experimentally  developed  in  animals  in  this  manner. 

Morbid  Anatomy.— The  gland  is  generally  somewhat  enlarged.  The 
interlobular  tissues  are  infiltrated  with  blood,  and  fat-necrosis  is  com- 
monly present.  An  accumulation  of  inflammatory  products  is  found 
around  the  acini.  Fat-necrosis  is  usually  found  also  in  the  omentum 
and  mesentery,  sometimes  in  other  regions. 

The  symptoms  are  the  same  as  those  of  pancreatic  hemorrhage.  These 
two  conditions  therefore  cannot  be  differentiated  clinically. 

2.  Acute  Suppurative  Pancreatitis  (Pancreatic  Abscess).— £f/o/o5/.— 
Two-thirds  of  the  cases  recorded  have  been  in  men.     The  cause  is  not 


CHRONIC  PANCREATITIS  541 

known.  That  it  is  due  to  infection  is  probable,  and  that  it  follows 
upon  an  inflammatory  condition  is  at  least  possible. 

Symptoms. — There  are  in  most  cases  attacks  of  severe  pain  and  vomit- 
ing, followed  by  fever  and  perhaps  delirium.  A  tumor  may  develop  in 
the  region.  When  the  condition  has  lasted  for  some  time,  fatty  diarrhea, 
glycosuria,  and  icterus  may  appear,  possibly  with  indications  of  sepsis. 

The  treatment  is  surgical.  One  case  diagnosticated  by  Thayer  and 
operated  upon  by  Finney  recovered,  but  the  diagnosis  has  rarely  been 
made. 

3.  Gangrenous  Pancreatitis. — The  entire  pancreas  or  only  a  portion 
of  it  may  undergo  necrosis.  The  cause  is  not  definitely  known,  except 
that  the  condition  sometimes  follows  injury,  hemorrhage,  hemorrhagic 
pancreatitis,  suppuration,  or  gastric  ulcer.  The  entire  pancreas  has  been 
found  separated  from  its  attachments  and  lying  in  an  abscess  cavity 
or  in  the  omental  cavity,  and  in  two  instances  the  gland  has  been  dis- 
charged per  rectum.  Recovery  followed  its  discharge  in  these  cases, 
but  in  most  instances  the  disease  has  proved  fatal  in  from  two  to  three 
weeks. 

CHRONIC   PANCREATITIS. 

Etiology. — The  disease  may  follow  one  or  more  attacks  of  the  acute 
form  of  pancreatitis,  but  it  is  generally  a  result  of  obstruction  of  the 
duct  by  calculi,  infection  by  micro-organisms,  or  the  extension  of  in- 
flammation along  the  pancreatic  duct  from  the  duodenum.  Inflamma- 
tion of  contiguous  structures,  especially  that  due  to  gall-stones,  alcohol- 
ism, or  syphilis,  has  been  regarded  as  the  cause  in  some  cases. 

Morbid  Anatomy. — The  pathological  change  is  a  sclerosis,  a  prolifer- 
ation of  the  interstitial  connective  tissue,  with  corresponding  destruction 
of  the  glandular  structure.  Small  cysts  are  sometimes  formed  through 
compression  of  the  pancreatic  duct  by  the  proliferated  tissue.  Inter- 
stitial hemorrhage  or  the  pigmentation  resulting  from  it  is  sometimes 
found.  Suppurative  pancreatitis  may  also  become  chronic  and  result 
in  the  formation  of  a  single  large  abscess  or  several  small  ones.  These 
may  subsequently  undergo  caseation  or  calcification. 

Symptoms. — The  symptoms  are  chiefly  those  of  gastric  and  intestinal 
indigestion,  with  occasional  attacks  of  epigastric  pain,  fever,  and  un- 
accountable prostration.  Jaundice  may  occur,  and  ascites  has  been 
observed.  Lipuria  and  fatty  stools,  with  undigested  muscle  fiber,  may 
also  be  present,  and,  if  the  destruction  of  the  gland  be  extensive,  gly- 
cosuria may  develop.  The  emaciation  may  be  extreme,  and  the  indurated 
gland  may  be  felt  through  the  abdominal  wall.  The  urine  usually  re- 
acts to  the  phenylhydrazin  test. 

FAT-NECROSIS. 

This  peculiar  change  is  liable  to  afifect  the  pancreas  and  the  adipose 
tissue  of  various  regions  in  connection  with  any  of  the  diseases  of  the 
gland,  particularly  with  the  hemorrhagic  or  gangrenous  forms  of  pan- 
creatitis. The  necrotic  tissue  is  circumscribed  and  appears  as  small 
yellowish  or  white  areas.  In  the  pancreas  these  are  seen  between  the 
lobules.     In  the  adipose  tissues  they  are  commonly  found  in  the  omen- 


542  PRACTICE  OF  MEDICINE 

turn  and  abdominal  fat,  but  they  may  be  found  in  the  fat  of  almost 
any  part  of  the  body.  The  cause  of  the  necrosis  is  not  known.  It  has 
been  attributed  to  almost  every  possible  accident  or  pathological  change, 
as  obstruction  of  the  duct,  deficient  circulation,  the  action  of  steapsin, 
the  fat-splitting  ferment,  and  very  naturally  to  the  action  of  various 
bacteria.  In  some  instances  the  pancreas  has  shown  no  recognizable 
disease.  The  recent  investigations  in  regard  to  the  islands  of  Langer- 
hans,  referred  to  under  the  Etiology  of  Diabetes,  may  lead  to  a  better 
explanation  of  this  disease. 

PANCREATIC  CYST. 

Etiology. — This  rare  disease  has  been  observed  in  both  males  and 
females,  chiefly  in  early  adult  or  middle  life,  but  congenital  cases  have 
been  recorded.  The  principal  causes  are :  (a)  Injury,  as  by  blows  or 
continued  pressure;  (Z")  extension  of  inflammation  from  the  duodenum ; 
(r)  obstruction  of  the  duct  by  calcuh  or  occlusion  by  pressure  (the 
retention  cysts  of  Korte);  (^)  the  presence  of  tumors,  including  the 
growth  of  cystic  adenomata;  or   (^)  sclerosis  of  the  gland. 

Morbid  Anatomy. — The  location  of  the  cyst  is  variable.  In  most 
instances  it  pushes  the  stomach  upward  and  the  colon  downward,  and 
it  may  reach  the  abdominal  wall  between  them.  It  may,  however,  be 
found  above  the  stomach  or  below  the  colon.  Again,  it  may  project 
into  the  region  of  the  left  kidney,  when  it  develops  from  the  tail  of  the 
pancreas.  It  varies  greatly  in  size,  sometimes  containing  only  a  few 
ounces,  sometimes  several  quarts,  of  fluid.  Communication  with  the  duct 
is  occasionally  established  in  some  cases,  and  the  size  of  the  tumor 
varies  with  the  escape  of  fluid  and  closure  of  the  opening.  The  contents 
of  the  cyst  may  be  mingled  with  blood,  or  clotted  blood  may  be  found  in 
it,  especially  in  cysts  of  traumatic  origin. 

Symptoms. — The  discovery  of  a  tumor  in  the  upper  portion  of  the 
abdomen  may  be  the  first  indication  of  a  cyst.  As  a  rule,  the  patient 
experiences  occasional  attacks  of  sudden,  severe  pain,  radiating  from 
the  epigastrium  downward  or  to  either  side,  often  to  the  left  shoulder. 
These  may  occur  spontaneously  or  after  an  error  of  diet,  and  they  are 
often  accompanied  with  vomiting,  constipation,  or  diarrhea,  perhaps 
with  bloody  dejections  and  jaundice.  Fatty  stools  are  rare,  but  the 
passage  of  undigested  meat  has  been  repeatedly  observed.  After  the 
tumor  has  attained  a  size  that  can  be  recognized,  the  symptoms  generally 
become  more  severe  and  the  nutrition  of  the  patient  rapidly  fails.  Dys- 
pnea may  be  produced  by  the  pressure  of  its  growth.  Glycosuria  has 
been  observed,  and,  rarely,  salivation. 

Diagnosis.— This  is  usually  based  upon  the  symptoms  described,  but 
particularly  upon  the  presence  of  a  semicircular  tumor  in  the  median 
line  or  on  either  side  of  it  in  the  upper  abdomen.  Sometimes  the  tumor 
becomes  extremely  large,  invading  almost  the  entire  cavity  of  the  abdo- 
men. It  does  not  move  with  respiration,  as  a  rule.  Fluid  aspirated 
from  it  is  generally  dark  brown,  of  alkaline  reaction,  and  has  a  specific 
gravity  between  i.oio  and  1.020  and  it  contains  fat-granules,  the  debris 
of  cells,  and  sometimes  cholesterin ;  but  the  most  valuable  diagnostic 
feature  is  the  fact  that  the  fluid  will  digest  fibrin  and  albumin.     All 


ACUTE  PERITONITIS  543 

three    pancreatic  ferments  are    sometimes    present,  but  the  others  are 
not  distinctive. 

Prognosis. — The  prognosis  is  favorable  under  proper  surgical  treat- 
ment. This  consists  in  opening  and  draining  the  cyst  under  proper 
precautions. 

TUMORS  OF  THE   PANCREAS. 

Cancer,  although  the  most  frequent  form  of  pancreatic  neoplasm,  is 
rare.  Sarcoma,  adenoma,  and  lymphoma  are  extremely  rare.  Syphilitic 
gummata  are  sometimes  observed.  The  cancer  is  generally  of  the  alve- 
olar type.  The  symptoms  are  not  distinctive,  hence  the  diagnosis  is 
often  difficult.  There  are  generally  paroxysms  of  pain,  nausea  and 
vomiting,  sometimes  jaundice,  with  rapid  emaciation  and  the  develop- 
ment of  cachexia.  The  tumor  may  often  be  felt,  but  its  location  is 
determined  with  difficulty.  Dilatation  of  the  stomach  sometimes  results 
from  compression  of  the  pylorus.  Fatty  stools,  glycosuria,  and  saliva- 
tion may  be  present,  and  ascites  sometimes  develops.  The  treatment 
is  purely  symptomatic,  unless  surgical  relief  is  attempted.  Extirpation 
has  been  successfully  performed  in  a  few  instances. 

PANCREATIC  CALCULI. 

Etiology. — Calculi  rarely  form  within  the  pancreatic  duct.  They  have 
usually  been  attributed  to  («;)  chronic  inflammation  of  the  gland  or  duct, 
(/^)  altered  secretion,  or  (r)  the  action  of  bacteria. 

Morbid  Anatomy. — The  calculi  are  usually  numerous,  small,  round 
or  irregular,  smooth  or  rough,  white  masses  consisting  chiefly  of  cal- 
cium carbonate  and  phosphate  and  varying  in  size  from  i  mm.  to  2.5 
cm.  in  diameter.  As  a  result  of  the  obstruction  occasioned  by  them, 
the  duct  becomes  dilated  and  a  greater  or  less  portion  of  the  gland 
may  become  inflamed,  with  the  production  of  chronic  induration  and 
possible  atrophy.  Cysts  are  often  formed,  and  carcinoma  has  been  attrib- 
uted to  the  irritation  occasioned  by  them. 

Symptoms. —These  are  little  more  definite  than  evidences  of  possible 
pancreatic  disease.  Occasional  attacks  of  pain  in  the  region  may  occur ; 
fatty  stools,  glycosuria,  and  emaciation  are  common  symptoms.  A 
positive  diagnosis  is  rarely  possible.  The  treatment  is  surgical  or  purely 
symptomatic,  if  the  case  does  not  admit  of  surgical  treatment. 

DISEASES  OF  THE  PERITONEUM. 

ACUTE   PERITONITIS. 

Definition. — An  acute  inflammation  of  the  peritoneum.  It  may  be 
either  primary  or  secondary  in  character,  general  or  local  in  extent. 

Etiology. — i.  Primary  Peritonitis.— This  form  of  the  disease  is  exceed- 
ingly rare,  if  we  retain  the  old  idea  that  it  originates  spontaneously, 
idiopathically,  or  from  no  more  definite  cause  than  exposure  and  cold. 
It  is  sometimes  thought  to  be  of  rheumatic  origin.  Such  cases  are 
doubtless  instances  of  cryptogenic  infection.    That  cases  occur  primarily. 


544  PRACTICE  OF  MEDICINE 

in  the  sense  that  they  are  preceded  by  no  other  specific  disease,  there 
is  little  doubt. 

2.  Secondary  Peritonitis. — This  form  may  arise  :  («;)  From  the  exten- 
sion of  inflammation  from  the  stomach,  intestines,  gall-bladder,  genito- 
urinary or  other  organs,  especially  after  perforation  has  occurred;  (^) 
from  the  passage  of  bacteria  through  the  intestinal  wall,  without  the  es- 
tablishment of  an  opening;  or  (<:)  from  injury. 

Peritonitis  due  to  perforation  is  the  most  common  form,  following 
the  rupture  of  an  ulcer  of  the  stom.ach,  bowel,  or  gall-bladder,  or  that 
of  an  abscess  anywhere  within  the  abdominal  cavity.  It  has  followed 
the  rupture  of  an  apparently  normal  Graafian  follicle  (Osier).  Peri- 
tonitis due  to  extension  of  inflammation  is  generally  associated  with 
ulceration,  suppurative  inflammation,  or  cancer  of  the  stomach,  intestine, 
liver,  spleen,  or  other  organs  and  tissues  having  a  peritoneal  investure, 
particularly  disease  of  the  appendix.  Fallopian  tubes,  or  ovaries.  The 
passage  of  bacteria  through  the  bowel  wall  is  by  no  means  infrequent. 
No  single  species  is  required  for  the  production  of  this  disease,  but 
many  are  doubtless  capable  of  exciting  it,  and  in  many  instances  two 
or  more  kinds  are  present.  Among  the  most  frequent  are  streptococci, 
staphylococci,  and  the  colon  bacillus,  especially  in  connection  with  fecal 
impaction  and  strangulation.  The  ameba  coli  has  been  found  in  cases 
arising  from  dysentery,  and  the  gonococcus  in  cases  from  tubal  disease. 
The  pneumococcus.  Bacillus  proteus,  pyocyaneus,  aerogenes  capsulatus, 
and  many  others  have  been  observed,  and  less  frequently  the  typhoid 
and  anthrax  bacilli.  Acute  peritonitis  often  follows  the  acute  infections, 
particularly  typhoid  fever,  scarlatina,  diphtheria,  cerebrospinal  men- 
ingitis, and  pneumonia,  and  it  occasionally  complicates  rheumatism, 
pleurisy,  chronic  nephritis,  septicemia,  and  tuberculosis.  Tubercular 
peritonitis  has  been  considered  under  the  general  subject  of  Tuberculosis. 
Septic  pleurisy  and  pericarditis  often  extend  to  the  peritoneum,  but 
it  is  due  to  the  passage  of  bacteria,  and  not  to  an  extension  of  the 
inflammation.  Septic  peritonitis  sometimes  occurs  in  infants  as  a  result 
of  infection  of  the .  cord. 

Injury  as  a  cause  of  peritonitis  includes  blows,  penetrating  wounds, 
and  infection  during  surgical  operations,  for  all  such  cases  are  due  to 
infection  following  the  injury  or  exposure  of  the  peritoneum. 

Morbid  Anatomy. — The  inflammation  may  be  of  any  of  the  varieties 
usually  met  with  in  the  serous  membranes,  especially  fibrinous,  sero- 
fibrinous, hemorrhagic,  purulent,  and  gangrenous.  (See  Inflammation, 
p.  29.)  When  the  inflammation  involves  the  entire  peritoneum,  it  con- 
stitutes a  general  peritonitis;  when  circumscribed,  possibly  shut  off" 
from  the  general  peritoneum  by  adhesions  of  its  own  surfaces,  it  is  a 
local  peritonitis.  The  character  of  the  inflammation  depends  upon  the 
infectious  agents  that  are  present,  largely  upon  the  ability  of  the  micro- 
organisms to  produce  suppuration.  Pus-formers  may,  however,  be 
found  in  a  simple  fibrinous  inflammation  of  recent  origin. 

Symptoms.  — Local. — Pain  is  usually  the  first  and  most  prominent 
manifestation  of  the  disease.  It  is  constant,  increasing  in  severity,  and 
generally  localized  or  most  intense  at  the  point  of  origin  of  the  inflam- 
mation. When  the  inflammation  originates  in  the  rupture  of  a  gastric 
ulcer,  the  pain  is  in  the  epigastrium,  or  even  more  frequently  it  is  re- 


ACUTE  PERITONITIS  545 

ferred  to  the  back  or  shoulders.  If  it  originates  from  disease  of  the 
appendix,  the  pain  is  greatest  in  that  region.  It  is  aggravated  by 
pressure  or  by  movement,  even  by  respiration.  On  this  account  the 
patient  Hes  with  his  knees  drawn  up,  and  his  breathing  is  shallow.  Vom- 
iting is  an  early  and  often  a  persistent  symptom,  and  the  bowels  are 
usually  constipated.  Sometimes  diarrhea  develops  and  vomiting  may 
be  absent,  but  eructations  are  usually  present  in  such  cases.  The  tongue, 
although  moist  and  coated  in  the  beginning,  generally  becomes  dry, 
brown,  and  perhaps  fissured.  Micturition  becomes  frequent  and  painful 
when  the  vesical  peritoneum  is  involved.  Retention  may  follow  from 
paralysis  of  the  muscular  coat  of  the  bladder,  or  it  may  be  caused  by 
the  administration  of  morphin.  The  urine  generally  contains  a  trace 
of  albumin  and  rather  large  quantities  of  indican.  In  cases  in  which 
the  sensibilities  are  obtunded,  notably  in  typhoid  fever,  the  pain  and 
tenderness  may  be  readily  overlooked  on  account  of  the  psychical  con- 
dition. The  abdomen  almost  always  becomes  distended,  soon  after  the 
onset  of  the  disease,  and  the  distention  often  becomes  extreme,  particu- 
larly when  the  abdominal  muscles  are  poorly  developed.  These  muscles, 
when  strong,  often  become  firmly  contracted  on  the  side  of  the  pain, 
and  may,  for  a  time  at  least,  produce  a  retraction  of  the  abdominal 
wall.  The  abdominal  distention  is  chiefly  due  to  the  accumulation  of 
gas  in  the  relaxed  bowel,  but  in  some  cases  in  part  to  the  accumulation 
of  serum  in  the  peritoneal  cavity. 

General  Symptoms. — In  the  beginning,  especially  in  perforative  and  sep- 
tic cases,  the  paroxysm  is  usually  accompanied  with  chilly  sensations 
or  a  distinct  rigor.  The  temperature  often  rises  rapidly  to  104°  or 
105°  F.  (40.0° — 40.5°  C.)  and  the  pulse  becomes  rapid,  small,  and  wiry, 
often  reaching  100  or  120  and  later  140  or  150.  The  respiration  is  also 
accelerated,  possibly  to  from  30  to  50,  and  shallow.  The  elevation  of 
the  diaphragm  and  the  rapid,  weak  action  of  the  heart  both  contribute 
to  the  embarrassment  of  respiration.  The  temperature  curve  becomes 
more  moderate  after  the  onset,  and  its  general  features  are  those  be- 
longing to  a  septic  infection.  The  evidences  of  suff'ering  soon  become 
apparent;  the  face  becomes  pinched,  moist,  and  shrunken,  often  deeply 
cyanotic,  brownish,  lead-colored,  or  livid,  and  the  expression  is  anxious 
unless  the  sensorium  is  obtunded  by  the  underlying  condition.  This 
so-called  Hippocratic  face  is  highly  indicative  of  the  disease.  Restless- 
ness usually  develops  and  there  may  be  mild,  muttering  delirium  or 
stupor.  A  persistent  hiccough  sometimes  develops.  In  asthenic  cases 
the  prostration  may  amount  to  collapse;  the  pulse  then  becomes  run- 
ning and  extremely  feeble,  and  the  extremities  cold  and  livid.  The  clini- 
cal picture  of  peritonitis  is  often  greatly  modified,  however,  by  the  fea- 
tures of  the  primary  disease. 

Physical  examination  reveals  the  abdominal  distention,  the  abdomen 
often  appearing  widened  or  the  rigidity  of  the  muscles  producing  extreme 
hardness,  even  concavity.  Palpation  reveals  also  extreme  tenderness, 
and  a  friction  fremitus  is  sometimes  perceptible,  but  not  so  uniformly 
as  in  chronic  peritonitis.  With  the  development  of  ascites,  fluctuation 
is  elicited.  Owing  to  the  elevation  of  the  diaphragm,  the  apex  beat  of 
the  heart  is  displaced  upward  and  toward  the  left.  Percussion  yields 
a  high-pitched  tympanitic  note  above  the  water-line  and  flatness  in  the 

35 


546  PRACTICE  OF  MEDICINE 

dependent  portions.  After  perforation  of  the  stomach  or  intestine,  the 
liver  dullness  is  often  absent,  but  the  same  effect  is  occasionally  pro- 
duced by  the  crowding  of  intestinal  coils  between  the  liver  and  the 
abdominal  wall.  The  upper  limit  of  hepatic  dullness  is  also  displaced 
upward.  The  spleen  may  be  unrecognizable.  In  some  cases  the  areas 
of  dullness  are  circumscribed  owing  to  the  formation  of  pouches.  Such 
pouches  may  occur  in  general  peritonitis,  although  more  characteristic 
of  the  localized  disease. 

The  course  of  the  disease  is  usually  rapidly  fatal,  terminating  in 
from  36  to  48  hours  in  the  worst  cases,  but  occasionally  running  a 
course  of  8  or  10  days.  The  average  duration  is  from  3  to  5  days. 
The  approach  of  death  is  generally  signalized  by  a  more  or  less  rapid 
failure  of  the  heart's  action  and  the  deepening  of  the  stupor.  The  breath- 
ing becomes  shallow,  the  lividity  of  the  skin  becomes  more  intense 
and  the  surface  colder,  but  the  rectal  temperature  becomes  higher.  Some- 
times the  %nd  is  instantaneous,  probably  through  cessation  of  the 
heart's  action. 

Diagnosis. — The  chilliness,  abdominal  tenderness,  pain,  and  distention, 
with  vomiting,  fever,  prostration,  and  Hippocratic  facies,  generally  estab- 
lish the  diagnosis.  But  some  symptoms  may  be  lacking.  The  previous 
history,  with  the  discovery  of  a  possible  cause,  whether  in  the  abdomen 
or  pelvis,  may  throw  needed  light  upon  the  condition.  The  diseases 
which  are  most  likely  to  cause  error  are  acute  enterocolitis,  obstruction 
of  the  bowel,  embolism  of  the  superior  mesenteric  artery,  and  the  so- 
called  hysterical  peritonitis. 

In  aacte  enterocolitis  the  pain  is  more  colicky  and  paroxysmal  and  the 
diarrhea  is  more  severe.  There  is  seldom  rigidity  of  the  abdomen  or 
persistent  elevation  of  the  knees. 

Intestinal  obstruction  often  presents  symptoms  so  like  those  of  peri- 
tonitis that  the  diagnosis  is  extremely  difficult.  The  chief  reliance  is 
then  to  be  placed  upon  the  history  of  the  case. 

Embolism  of  the  superior  mesenteric  artery  causes  sudden,  severe  pain, 
vomiting,  and  collapse,  which  cannot  for  a  time  be  differentiated.  The 
rectal  temperature  would  not,  however,  be  elevated.  Rupture  of  abdom- 
inal aneurism,  although  generally  instantly  fatal,  has  been  suggested 
as  a  possible  source  of  error. 

Hysterical  peritonitis  can  generally  be  differentiated  through  the  pres- 
ence of  other  hysterical  manifestations.  There  is  the  usual  exagger- 
ation of  symptoms  and  a  cessation  of  them  when  the  attention  has 
been  diverted. 

LOCALIZED    PERITONITIS. 

Of  this  there  are  three  principal  forms,  corresponding  to  the  location 
and  origin  of  the  disease,  namely,  subphrenic,  appendicular,  and  pelvic, 
(i)  The  first  of  these,  the  subphrenic  abscess,  has  been  described  under 
the  head  of  Perihepatitis  (p.  522). 

(2)  Appendicular  Peritonitis.— T!\\&  is  the  most  frequent  form  of  peri- 
tonitis in  males  and  is  due  to  inflammation  about  the  appendix.  Its 
location  corresponds  to  the  varying  locations  of  the  appendix.  The 
localization  of  the  inflammation  is  due  to  the  early  formation  of  ad- 
hesions between  the  layers  of  the  peritoneum,  which  completely  shut  out 


ACUTE  PERITONITIS  547 

a  limited  portion  from  the  general  cavity.     Complete  healing  with  oblit- 
eration of  the  appendix  sometimes  results  from  it. 

(3)  Pelvic  peritonitis  results  from  inflammation  about  the  uterus 
and  more  particularly  about  the  Fallopian  tubes.  The  disease  is  gen- 
erally septic,  gonorrheal,  or  tubercular  in  character.  Here,  too,  the 
process  may  be  completely  shut  off  from  the  general  peritoneum,  and 
recovery  is  possible,  but  not  infrequently  the  arrest  is  but  temporary, 
an  abscess  is  perhaps  formed  which  ultimately  ruptures  into  the  general 
peritoneal  cavity,  or  a  tuberculous  infection  may  extend  in  the  usual 
manner  from  the  localized  focus  to  the  general  cavity. 

Prognosis  of  Peritonitis. — Acute  general  peritonitis  is  an  exceedingly 
dangerous  disease.  Its  course  depends  chiefly  upon  the  cause,  and  the 
character  of  the  exudate.  When  it  has  arisen  from  the  perforation  of 
a  gastric  or  intestinal  ulcer  or  from  the  rupture  of  an  abscess,  it  is 
almost  inevitably  fatal.  That  due  to  puerperal  sepsis  or  induced  abor- 
tion is  also  fatal,  as  a  rule.  In  other  forms  of  localized  peritonitis,  the 
prognosis  is  less  unfavorable. 

Treatment. — The  severity  of  the  pain  demands  the  hypodermic  admin- 
istration of  morphin,  gr.  ^  to  ^  (o.oi — 0.02),  at  short  enough  inter- 
vals to  keep  the  patient  comfortable,  but  with  caution.  The  fact  that 
patients  with  peritonitis  require  large  doses  of  opium  is  not  true  of  the 
hypodermic  administration  of  morphin.  The  patient  should  be  propped 
with  pillows  in  a  position  that  is  most  comfortable,  the  knees  being 
well  drawn  up.  Hot  fomentations  or  turpentine  stupes  applied  to  the 
abdomen  at  short  intervals  are  soothing.  In  some  instances,  cloths 
wrung  out  of  ice-water  are  more  agreeable.  Hot-water  bottles,  ice- 
bags,  and  poultices  are  generally  objected  to  on  account  of  their  weight. 
The  application  of  twenty  or  thirty  leeches  is  sometimes  beneficial. 

The  administration  of  laxatives  in  peritonitis  was  strongly  advo- 
cated a  few  years  ago,  as  a  reversal,  perhaps,  from  a  too  free  resort 
to  opium.  At  the  present  time  there  are  probably  few  who  would  with- 
hold morphin  during  the  painful  period,  yet  there  are  some  who  recom- 
mend the  administration  of  saline  laxatives  in  concentrated  solution, 
believing  that  it  favors  the  exosmosis  of  serum  from  the  blood-vessels 
of  the  intestine,  and  through  it  the  removal  of  collateral  edema.  The 
increased  peristalsis  is  believed  to  prevent  the  danger  of  peritoneal 
adhesions.  Much  success  has  been  claimed  for  the  treatment,  but,  as 
Osier  frankly  remarks,  the  reports  of  cases  do  not  always  convince  one 
that  peritonitis  actually  existed.  As  in  other  inflammatory  conditions, 
rest  is  essential.  The  saline  treatment  may  be  resorted  to  after 
operation,  but  never  in  cases  due  to  perforation.  Vomiting  is  some- 
times arrested  by  the  morphin;  otherwise  it  may  yield  to  a  total 
suspension  of  all  food  and  drink.  Sometimes  the  giving  of  small  frag- 
ments of  ice  or  sipping  hot  water  or  hot  brandy  will  check  it.  The 
meteorism  is  often  relieved  by  lavage  of  the  stomach  and  rectal 
injections  of  cold  water.  The  passage  of  the  rectal  tube  sometimes 
gives  exit  to  a  large  quantity  of  gas.  The  diet  should  consist  chiefly 
of  milk,  either  hot  or  cold,  plain  or  with  the  addition  of  lime-water  or 
a  carbonated  water.  Peptonized  milk  is  preferred  by  some  writers. 
If  it  cannot  be  retained,  rectal  alimentation  may  be  resorted  to.  Whisky 
and  strychnin  should  be  given  freely  to  support  the  strength. 


548  PRACTICE  OF  MEDICINE 

The  possibility  of  surgical  interference  should  be  considered  at  the 
very  beginning,  and  a  surgeon  should  generally  be  consulted.  In  all 
cases  of  localized  peritonitis,  and  particularly  when  the  inflammation 
is  spreading,  the  surgical  treatment  offers  greater  hope  for  recovery  than 
the  medical,  which  is,  after  all,  only  palliative. 

CHRONIC  PERITONITIS. 

This  may  be  either  local  or  general  in  extent,  adhesive,  proliferative, 
or  hemorrhagic  in  character.  The  disease  may  be  the  outcome  of  the 
acute  form,  but  it  is  more  frequently  tubercular  or  cancerous. 

(i)  Local  Adhesive  Peritonitis.— This  is  a  common  form,  occurring 
particularly  after  appendicitis,  and  very  often  found  over  the  surface 
of  the  spleen  and  liver  after  localized  acute  inflammation.  These  organs 
are  firmly  bound  to  the  overlying  structures — the  liver  and  spleen  to 
the  diaphragm,  the  appendix  to  the  nearest  structures,  and  the  coils  of 
the  intestine  are  usually  firmly  matted  or  connected  by  fibrous  bands. 
Strangulation  of  the  intestine  sometimes  results  from  the  passage  of 
a  loop  through  the  abnormal  opening  thus  formed. 

(2)  General  Adhesive  Peritonitis.— This  form  may  result  from  an 
acute  attack,  but  it  often  develops  in  connection  with  such  diseases  as 
hepatic  cirrhosis  or  chronic  passive  congestion.  The  peritoneum  be- 
comes thickened,  adhesions  form  between  all  contiguous  surfaces,  until 
the  entire*  sac  may  be  obliterated  and  the  intestinal  coils  completely 
matted  together.  There  are  sometimes  great  thickening  and  deformity 
of  the  omentum  and  mesentery.  The  liver  and  spleen  are  covered  with 
a  thick  layer  of  fibrin,  and  a  friction  fremitus  may  sometimes  be  felt 
or  the  surface  may  become  completely  united  with  the  diaphragm  and 
other  contiguous  structures.  Any  part  of  the  cavity  that  is  not  entirely 
obliterated  is  generally  filled  with  serum,  which  may  be  clear,  but  is 
generally  turbid  with  fibrin,  cellular  debris,  or  occasionally  with  pus. 

(3)  Proliferative  Peritonitis.— The  peritoneum  becomes  gradually 
thickened,  but  the  surfaces  are  not  uniformly  adherent.  Moderate  efl'u- 
sion  is  generally  present,  occasionally  a  pronounced  ascites.  The  thick- 
ening is  not  uniform.  The  omentum  is  occasionally  rolled  into  a  hard 
mass  extending  across  the  abdomen  between  the  stomach  and  colon. 
In  some  cases  the  liver  and  spleen  are  covered  by  a  thick  mass  of  almost 
cartilaginous  firmness,  and  a  similar  condition  may  be  encountered 
in  other  regions.  Small  nodular  masses  grossly  resembling  tubercles 
are  sometimes  found.  The  mesentery  may  be  much  shortened  by  the 
contraction  of  the  new  tissue.  The  gastrohepatic  omentum  may  be 
contracted  and  the  portal  vein  compressed,  the  liver,  spleen,  and  other 
organs  reduced  in  size,  and  the  walls  of  the  intestine  so  contorted  that 
the  mucous  membrane  is  thrown  into  large  folds.  The  peritoneal  cavity 
may  be  divided  into  compartments  as  in  tubercular  peritonitis,  with 
a  variable  quantity  of  fluid  in  each.  This  form  of  the  disease  is  met 
with  especially  in  alcoholic  subjects,  often  in  connection  with  hepatic 
cirrhosis.  The  friction  fremitus  is  sometimes  felt  in  this  form,  as  it 
may  be,  at  times,  in  all  others. 

(4)  Chronic  Hemorrhagic  Peritonitis.— In  this  unusual  form,  described 
by  Virchow,  the  peritoneum  is  here  and  there  covered  with  a  layer  of 


ASCITES 


549 


new  connective  tissue  possessing  large  vessels  from  which  an  extrav- 
asation of  blood  occasionally  occurs  and  forms  a  hemorrhagic  lay-er. 
Such  alternating  layers  are  met  with  particularly  in  the  pelvis.  The 
blood-stained  effusions  sometimes  found  within  the  cavity  in  tubercular 
and  cancerous  peritonitis  are  not  indicative  of  this  form  of  peritonitis. 

Symptoms. — Chronic  peritonitis  frequently  presents  iew  or  no  symp- 
toms, following  so  insidiously  upon  an  acute  attack  that  recovery  is 
thought  to  have  taken  place.  Pain  and  tenderness  are  generally  pres- 
ent, but  there  may  be  little  or  no  distention.  Fever  may  occasionally 
.  develop.  All  the  symptoms  are  intermittent  in  their  appearance.  The 
action  of  the  bowels  is  irregular.  The  patient  becomes  anemic,  ema- 
ciated, and  feeble.  The  diagnosis  is  difficult  and  the  condition  is  often 
overlooked  during  life. 

Treatment. — Little  can  be  accomplished  through  medicinal  treatment 
further  than  to  support  the  strength  and  allay  the  pain.  Benefit  has 
been  claimed  for  inunctions  of  ichthyol  or  mercurial  ointments. 

CANCER  OF  THE  PERITONEUM. 

Cancer  rarely  attacks  the  peritoneum  primarily,  but  may  reach  it 
directly  or  through,  metastasis  from  a  primary  focus  in  some  adjacent 
part  of  the  gastrointestinal  canal.  Any  form  of  the  disease  may  be 
encountered,  but  the  encephaloid,  scirrhous,  and  colloid  are  the  more  com- 
mon. One  or  more  large  masses  may  be  developed,  or  there  may  be  nu- 
merous small  nodules.  The  disease  occurs  only  after  the  usual  age 
limit,  and  is  more  frequent  in  women  than  in  men. 

Symptoms  .—The  manifestations  of  the  disease  are  those  of  local,  or, 
more  frequently,  of  chronic  peritonitis.  The  diagnosis  can  rarely  be 
made  unless  the  primary  focus  be  recognized,  for  it  is  often  only  after 
tapping  that  it  is  possible  to  feel  the  nodules  that  are  present.  It  is 
not  always  possible  then  to  differentiate  the  nodules  from  those  of 
tuberculosis.  The  presence  of  a  large  number  of  tumors,  however,  favors 
the  diagnosis  of  cancer.  In  colloid  cancer,  the  peritoneal  cavity  may  be 
found  distended  with  a  thick,  gelatinous  colloid  matter  instead  of  serum. 

The  prognosis  is  always  unfavorable,  and  the  treatment  is  wholly 
palliative. 

ASCITES. 

ABDOMINAL  DROPSY,   HYDROPERITONEUM. 

Definition. — An  accumulation  of  serous  fluid  within  the  peritoneal  cav- 
ity.   It  is  a  symptom  common  to  many  diseases. 

Etiology. — Ascites  is  met  with  in  either  sex  and  at  any  time  of  life,  so 
many  are  the  conditions  that  may  give  rise  to  it.  It  may  be  due  to  ei- 
ther local  or  general  causes. 

(i)  Local  Causes. — The  most  important  of  these  are:  (rt)  Chronic 
inflammation  of  the  peritoneum,  which  may  be  simple,  tubercular,  or 
cancerous;  ((^)  obstruction  of  the  portal  circulation,  as  in  cirrhosis, 
cancer,  or  other  diseases  of  the  liver,  chronic  passive  congestion  due  to 
heart  disease  or  chronic  pulmonary  disease,  or  thrombosis;  or  through 
the  pressure  or  growth  of  tumors,  peritoneal  contractions  or  adhesions. 


550  PRACTICE  OF  MEDICINE 

The  pressure  of  tumors  or  aneurism  upon  the  lymph-vessels,  hepatic 
vein,  or  inferior  vena  cava  is  also  a  possible  cause;  (^)  the  growth 
of  solid  tumors  within  the  abdomen,  less  frequently  an  enlargement  of 
the  spleen,  as  that  due  to  malaria. 

(2)  General  Causes. — These  are  :  (ji)  Conditions  which  lead  to  general 
dropsy,  as  valvular  heart  disease,  chronic  emphysema,  or  so-called 
fibroid  phthisis;  (Ji)  altered  conditions  of  the  blood  which  favor  the 
transudation  of  serum,  as  in  chronic  malaria,  chronic  nephritis,  cancer, 
amyloid  disease,  or  syphilis.  (<;)  Two  other  forms  of  ascites  should 
be  mentioned.  The  first  is  due  to  the  escape  of  fluid  from  the  lac- 
teal vessels  as  a  result  of  injury,  ulceration,  or  other  disease,  com- 
pression of  the  thoracic  duct  or  thrombosis  of  the  left  subclavian  near 
its  entrance,  or  to  the  presence  of  filaria,  and  known  as  chylous  ascites. 
The  other  is  due  to  fatty  cellular  degeneration  with  the  production  of 
so-called  adipose  ascites,  a  rare  form  generally  associated  with  cancer 
or  tuberculosis. 

Symptoms. — The  first  symptom  is  usually  a  gradually  increasing  dis- 
tention of  the  abdomen.  This  is  often  overlooked  by  the  patient,  how- 
ever, until  other  evidence  of  dropsy  appears.  Sometimes  there  is  a  sense 
of  fullness  and  weight,  and  as  the  accumulation  increases,  respiration 
is  interfered  with.  Gastrointestinal  disturbances  and  alterations  of  the 
quantity  and  character  of  the  urine  are  often  observed,  but  they  are 
generally  referable  to  the  condition  producing  the  ascites. 

Physical  Examination. — Inspection. — The  abdomen  is  prominent,  often 
flattened  at  the  sides.  When  the  distention  is  great,  the  skin  becomes 
stretched  and  glazed,  and  lineae  albicantes  may  be  produced.  The  super- 
ficial veins  are  distended,  those  of  the  abdomen  becoming  continuous 
with  dilated  branches  of  the  external  mammary,  and  the  circulation 
may  be  found  to  be  reversed,  passing  from  below  upward,  as  can  be 
demonstrated  by  pressure.  Around  the  navel  there  is  sometimes  a  vari- 
cose wreath  known  as  the  caput  Medusae.  The  umbilicus  may  pro- 
trude, rarely  it  appears  to  be  obliterated.  The  respiratory  movements 
are  almost  entirely  thoracic. 

Palpation  reveals  fluctuation  when  the  accumulation  amounts  to  sev- 
eral liters.  This  is  brought  out  by  placing  one  hand  upon  the  side  of 
the  abdomen,  and  striking  a  sharp,  quick  blow  with  the  fingers  of  the 
other  hand  at  a  corresponding  point  on  the  opposite  side. 

Percussion  elicits  dullness  over  the  fluid,  which  gravitates  to  the  most 
dependent  region  in  the  diff'erent  positions  that  the  patient  may  occupy, 
and  a  tympanitic  note  over  the  intestines,  which  float  above  the  fluid. 
When  the  patient  stands,  the  dullness  is  in  the  lower  part,  rising  a  vari- 
able distance  above  the  brim  of  the  pelvis ;  when  he  is  in  the  recumbent 
posture,  it  is  along  the  flanks.  A  small  quantity  of  fluid  can  sometimes 
be  recognized  by  placing  the  patient  in  the  knee-elbow  position  and  per- 
cussing over  the  most  dependent  area. 

Diagnosis. — The  recognition  of  ascites  is  not  difficult  when  the  accu- 
mulation of  fluid  is  sufficient  to  cause  distention,  dullness,  and  fluctua- 
tion. Less  than  a  quart  (liter)  of  fluid  cannot  be  detected  with  cer- 
tainty. The  principal  condition  to  be  excluded  is  ovarian  cyst,  but 
pancreatic  cyst,  echinococcus  cyst,  pregnancy,  and  a  distended  bladder 
are  possible  sources  of  error. 


ASCITES 


551 


Ovarian  cyst  is  generally  preceded  by  normal  health  or  by  nothing 
more  serious  than  dysmenorrhea.  The  distention  is  at  first  unilateral, 
and  it  usually  remains  asymmetrical  until  the  tumor  becomes  extremely 
large.  The  fluctuation  is  limited  to  a  definite  area,  and  does  not  change 
with  change  of  position.  Vaginal  examination  reveals  uterine  displace- 
ment; sometimes  the  cyst  can  be  felt.  The  fluid  accumulates  after  as- 
piration much  more  slowly  than  does  that  of  ascites.  The  ascitic  fluid 
is  usually  of  a  clear,  pale  straw-color,  and  has  a  specific  gravity  of 
from  1. 010  to  1. 015,  while  that  of  ovarian  cyst  is  turbid  and  1.020  or 
over.  The  ovarian  fluid  is  often  highly  albuminous,  and  does  not  coagu- 
late spontaneously,  as  the  ascitic  fluid  may  do.  Cholesterin  may  be 
found  in  the  ovarian,  but  not  in  the  ascitic  fluid.  Echinococcus  and  pan- 
creatic cysts  are  readily  excluded  by  the  character  of  their  fluid.  The 
echinococcus  fluid  contains  booklets  and  fragments  of  the  chitinous  mem- 
brane, that  of  the  pancreatic  cyst  the  digestive  ferments.  The  distended 
bladder  should  not  cause  error,  for  it  is  immediately  relieved  on  cathe- 
terization. In  pregnancy,  the  fetal  heart,  the  movements,  and  other 
signs  are  sufficient  for  a  diagnosis,  if  proper  examination  be  made, 
regardless  of  the  quantity  of  amniotic  fluid,  the  only  source  of  error. 

Prognosis. — The  presence  of  ascites  is  always  of  serious  import,  for 
it  often  indicates  the  approach  of  the  fatal  termination  of  the  under- 
lying disease;  yet  ascites  has  lasted  from  ten  to  twenty  years.  All  de- 
pends upon  the  gravity  of  the  causative  disease. 

Treatment. — The  treatment  of  ascites  embraces  the  application  of 
therapeutic  and  other  agencies  for  the  removal  of  the  fluid.  The  general 
management  of  the  patient  and  measures  to  obtain  a  permanent  cure 
belong  to  the  treatment  of  the  disease  causing  the  condition.  It  some- 
times happens,  particularly  in  cirrhosis  of  the  liver,  that  a  systematic 
withdrawal  of  the  fluid  greatly  favors  the  production  of  changes  in  the 
circulation,  which,  for  a  time  at  least,  check  the  formation  of  the  effu- 
sion. 

Hydragogue  cathartics  are  usually  first  resorted  to,  especially  when 
the  condition  depends  upon  disease  of  the  heart  or  kidneys.  A  dram 
(4.0)  of  compound  jalap  powder  should  be  administered  on  alternate 
mornings.  Potassium  bitartrate  in  large  doses  is  to  be  preferred  in  many 
cases.  It  may  be  conveniently  added  to  lemonade  to  be  drunk  during 
the  day.  Magnesium  sulphate  in  large  doses  and  concentrated  solution 
an  hour  before  breakfast  often  acts  well.  Diuretics  may  be  adminis- 
tered with  benefit  when  they  are  not  contraindicated  by  the  condition 
of  the  patient.  Repeated  small  doses  of  calomel,  alone  or  with  digitalis, 
may  prove  effective,  particularly,  however,  in  cases  of  heart  disease. 
Tapping  often  becomes  necessary,  and  should  not  be  too  long  delayed, 
especially  in  hepatic  cirrhosis. 


SECTION    VII. 
Diseases  of  the  Kidneys. 


ANOMALIES  OF  FORM  AND  POSITION. 

Anomalies  of  form  and  position  are  thus  classified  by  Newman  :  A. 
Displacements  without  mobility,  (i)  Congenital  displacement;  (2)  con- 
genital displacement  with  deformity;  (3)  acquired  displacement. — B. 
Malformations,  (i)  Variations  in  number:  (a-)  Supernumerary  kid- 
ney; (<5')  single  kidney,  congenital  absence  of  one  kidney,  atrophy  of 
one  kidney,  absence  of  both  kidneys.  (2)  Variations  in  form  and  size  : 
(«)  General  variation  in  form,  lobulation,  etc. ;  (<^)  hypertrophy  of 
one  kidney;  (r)  fusion  of  two  kidneys,  horseshoe  kidney,  sigmoid  kid- 
ney, disk-shaped  kidney. — C.  Variations  in  pelvis,  ureters,  and  blood- 
vessels.   It  is  rarely  that  these  anomalies  assume  clinical  importance. 

MOVABLE  KIDNEY. 

FLOATING  KIDNEY,   PALPABLE  KIDNEY,  NEPHROPTOSIS. 

Definition. — A  condition  of  abnormal  mobiUty  of  the  kidney,  much 
more  frequent  in  the  right,  sometimes  affecting  both  kidneys. 

Etiology. — The  condition  is  rarely  congenital.  The  acquired  form  is 
much  more  frequent  in  women.  In  some  instances  it  is  due,  in  part  at 
leajst,  to  an  abnormal  congenital  looseness  or  to  a  relaxation  of  peri- 
toneal attachments  with  unusual  length  of  the  renal  artery.  The  con- 
dition is  often  associated  with  enteroptosis.  An  important  factor  in 
many  cases  is  tight-lacing  or  the  relaxation  of  the  abdominal  walls  by 
repveated  pregnancies.  Emaciation  favors  its  production.  Trauma,  as 
by  falls,  and  lifting  have  been  influential  in  some  instances. 

Symptoms. — That  the  condition  may  exist  without  producing  symp- 
toms is  shown  by  its  occasional  discovery  during  physical  examination 
for  other  conditions,  or  upon  the  post-mortem  table.  In  some  cases, 
however,  persistent  or  intermittent  disturbances  occur  which  may  be 
considered  under  the  heads  of  local  and  reflex  symptoms. 

1.  Local  Symptoms. — A  sense  of  dragging  weight  or  pressure  in  the 
loins  or  abdomen  or  an  intercostal  neuralgia  is  often  complained  of, 
esp>ecially  after  fatigue.  Severe  pain  or  reflex  symptoms  sometimes 
arise,  apparently  from  a  sudden  change  in  the  position  of  the  aftected 
kidney. 

2.  Reflex  Symptoms. — The  reflex  manifestations  may  be  confined  to 
the  abdominal  region,  or  they  may  be  general.  They  are  intermittent, 
as  a  rule,  and  may  be  intensified  by  any  influence  which  aggravates 
the  abnormal  condition,  as  by  a  sudden  change  of  the  location  of  the 
organ.      Reflex    gastrointestinal    disturbances    are   common.      Nausea, 


MOVABLE  KIDNEY  553 

vomiting,  indigestion,  and  constipation  can  often  be  distinctly  traced 
to  the  renal  displacement;  but  such  conditions  as  gastric  dilatation 
and  icterus  are  probably  no  more  than  coincident  conditions.  Cardiac 
palpitation,  anasarca,  intestinal  obstruction,  and  functional  disorders  of 
the  uterus  have  been  attributed  to  the  pressure  of  a  dislocated  kidney. 

Dietl's  crises  are  almost  distinctive.  They  consist  of  sudden,  sometimes 
periodical,  attacks  of  sharp  abdominal  pain,  with  chill,  fever,  nausea, 
vomiting,  and  collapse,  probably  due,  as  Dietl  thought,  to  compression 
or  twisting  of  the  ureter.  They  may  be  induced  also  by  overindulgence 
in  food  or  strong  drink.  During  the  attack  the  urine  usually  becomes 
highly  colored  and  charged  with  uric  acid  and  oxalates,  sometimes  con- 
taining also  blood  and  pus.  Albuminuria  or  hemoglobinuria  may  be 
present.  The  displaced  kidney  becomes  swollen  and  tender.  The  com- 
pression of  the  ureter  sometimes  leads  to  permanent  or  intermittent 
hydronephrosis. 

The  general  reflex  symptoms  usually  assume  the  form  of  hysteria, 
neurasthenia,  or  simple  nervousness,  with  anxiety  and  melancholia,  es- 
pecially pronounced  for  a  time  after  the  discovery  of  the  tumor. 

Physical  Examination. — The  patient  should  be  placed  on  the  back, 
v/ith  the  head  low  and  the  abdominal  walls  thoroughly  relaxed.  Bi- 
manual palpation  is  then  practiced  with  the  left  hand  over  the  lumbar 
region  behind  the  last  ribs,  and  the  right  over  the  hypochondriac  re- 
gion. The  kidney,  if  sufficiently  displaced,  can  be  felt,  as  a  firm,  globular 
body,  just  below  the  margin  of  the  liver.  Sometimes  it  is  possible  to 
feel  the  lower  edge  of  the  kidney  only  when  the  patient  takes  a  full 
inspiration.  This  is  called  a  palpable  kidney.  If  the  entire  organ  can 
be  felt  and  the  finger  passed  above  the  upper  margin  of  it  during  in- 
spiration, it  is  known  as  the  movable  kidney.  If  the  organ  can  be  de- 
pressed below  the  level  of  the  umbilicus,  it  is  designated  a  floating  kid- 
ney. To  this  class  belong  those  rare  instances  in  which  the  kidney 
sinks  into  the  pelvis. 

Diagnosis. — Few  conditions  are  likely  to  be  confounded  with  this  after 
careful,  thorough  examination.  A  floating  kidney  is  often  momentarily 
suggested  by  a  movable  cancer  of  the  pylorus,  fibromata,  or  secondary 
carcinomata  of  the  omentum  or  intestine,  fecal  impaction,  tumors  of 
the  gall-bladder  or  ovary,  and  movable  spleen.  But  the  peculiar  kidney 
shape,  with  notched  edges,  can  seldom  be  mistaken,  and  still  more  sig- 
nificant is  the  peculiar  feeling  of  nausea  that  is  induced  by  pressure 
upon  it. 

Treatment.— It  is  often  advisable  to  withhold  from  the  patient  the  na- 
ture of  the  condition,  especially  when  the  displacement  is  so  slight  as 
to  be  classed  with  the  palpable  or  movable  kidneys,  and  when  it  pro- 
duces no  serious  disturbance.  When,  however,  painful  crises  occur,  more 
or  less  radical  measures  may  become  necessary.  Sometimes  the  organ 
can  be  replaced  by  taxis,  and  nothing  more  is  necessary  than  rest  in  bed 
until  the  pain  has  subsided.  Morphin  must  sometimes  be  administered. 
After  a  paroxysm  the  patient  should  avoid  jolts  and  jars,  lifting  and 
other  possible  causes  of  the  crises.  It  is  often  necessary  to  treat  the 
neurasthenic  condition  of  the  patient  rather  than  the  renal  condition. 
Relief  often  follows  a  decided  gain  of  adipose  tissue.  Surgical  measures 
are  required  in  extreme  cases.    The  kidney  capsule  may  be  stitched  to 


554  PIL\CTICE  OF  MEDICINE 

the  abdominal  wall  (nephrorrhaphy),  but  the  result  is  not  always  per- 
manent. Extirpation  of  the  kidney  is  a  more  serious  operation,  often 
successful,  sometimes  fatal,  and  the  loss  of  one  kidney  in  itself  is  not 
always  free  from  injurious  effects. 

HYPEREMIA  OF  THE  KIDNEY. 

Hyperemia  may  be  active  or  passive,  acute  or  chronic.  Etiology. — 
Active  hyperemia  is  always  present  in  the  early  stage  of  acute  paren- 
chymatous nephritis,  and  it  is  not  always  possible  to  distinguish 
clearly  between  a  simple  hyperemia  and  that  of  Bright' s  disease.  The 
former  condition  is  frequently  induced,  however,  by  :  (^a)  The  toxemia  of 
the  acute  infectious  diseases,  probably  the  most  frequent  cause,  or  (^F) 
such  irritant  drugs  as  turpentine,  cantharides,  copaiba,  carbolic  acid, 
potassium  chlorate,  phosphorus,  arsenic,  and  alcohol,  (i-)  It  is  supposed 
,to  occur  in  one  kidney  after  sudden  arrest  of  the  function  of  the  other. 

Morbid  Anatomy. — The   kidney  is  large,   of  dark  red  color,  the  cap- 
sule is  tense,  but  not  adherent,  and  blood  flows  from  the  cut  surface. 
The  columnar  epithelium  is  cloudy  and  desquamating,  as  in  acute  ne- 
phritis. 

Symptoms. — The  urine  may  be  increased  and  of  low  specific  gravity, 
or  diminished  and  of  higher  specific  gravity.  Albumin  and  oxalates, 
sometimes  blood,  are  found  in  it.  The  treatment  consists  in  removal 
of  the  cause  if  recognized,  rest  in  bed  and  milk  diet  for  a  few  days. 
When  the  hyperemia  is  extreme,  and  especially  if  strangury  or  anuria 
develop,  the  hot  pack  and  dry  cups  to  the  region  of  the  kidneys  are 
beneficial.  Internal  medication  is  not  usually  necessary,  and  diuretics 
may  prove  injurious. 

Passive  Hyperemia. — Etiology. — This  condition  is  induced  (<z)  By  any 
influence  which  retards  the  flow  of  blood  through  the  ascending  vena 
cava,  as  chronic  valvular  disease  of  the  heart,  emphysema,  interstitial 
pneumonia,  myocarditis,  obliterative  pericarditis,  or  arteriosclerosis; 
(^b^  by  the  secondary  collateral  obstruction  in  hepatic  cirrhosis;  and 
(r)  by  compression  of  the  renal  veins  by  tumors,  the  gravid  uterus,  or 
ascitic  fluid. 

Morbid  Anatomy.— The  kidney  is  large,  often  intensely  congested,  the 
cortex  is  deep  red  and  the  pyramids  purple.  The  capsule  becomes  more 
or  less  adherent,  and  the  cut  surface  bleeds  freely.  The  substance  is  firm, 
especially  in  the  heart-kidney,  owing  to  hyperplasia  of  the  connective 
tissue,  intertubular  cellular  infiltration,  and  not  infrequently  thickening 
of  the  glomerular  capsule.  The  condition  cannot  always  be  differentiated 
from  diffuse  nephritis,  into  which  it  usually  merges. 

Symptoms. — These  are  for  the  most  part  confined  to  the  concentration 
of  the  urine,  diminution  of  quantity,  with  increase  of  color  and  sohd  in- 
gredients. Albumin  and  casts  are  present  and  sometimes  blood-cor- 
puscles. Uremic  symptoms  may  develop  in  severe  cardiac  cases.  Edema 
of  the  lower  extremities,  dyspnea,  and  gastrointestinal  disturbances 
often  accompany  the  condition,  but  they  are  attributable  to  the  cardiac 
incompetency. 

Treatment.— The  treatment  must  be  directed  in  most  instances  to  the 
cardiac   condition.     Digitalis  and  nitroglycerin  may  be    indicated,  the 


ANOMALIES  OF  RENAL  SECRETION  555 

latter  especially  to  stimulate  the  renal  circulation.  Hot  applications 
or  dry  cups  over  the  kidneys  are  sometimes  of  benefit.  When  extreme 
congestion,  threatening  life,  results  from  pregnancy,  it  is  sometimes  nec- 
essary to  induce  labor.  The  diet  should  be  liquid,  chiefly  milk.  Diu- 
retics should  be  employed  with  caution,  if  at  all. 

ANOMALIES  OF  SECRETION. 

Anuria. — Total  suppression  of  the  urine  occurs  under  a  variety  cf 
causes,  (i)  It  may  be  encountered  in  the  new-born  infant  as  a  result 
of  absence  of  the  kidneys,  a  condition  incompatible  with  life  of  more 
than  a  few  days'  duration;  (2)  it  occurs  as  a  symptom  of  severe  acute 
nephritis;  (3)  as  a  result  of  the  obstruction  of  both  ureters  with  cal- 
culi, usually  occurring  in  men;  (4)  as  a  result  of  toxemia  in  the  various 
acute  infectious  diseases,  especially  cholera,  yellow  fever,  or  the  irritant 
diuretics  referred  to  as  causes  of  hyperemia  of  the  kidneys;  (5)  from 
extensive  disease  or  excision  of  a  single  kidney;  or  (6)  as  a  result  of 
the  collapse  following  injury,  surgical  operations,  or  the  passage  of  the 
•catheter.  It  sometimes  occurs  also  as  a  manifestation  of  hysteria,  but 
retention  and  deception  are  more  common  in  this  connection. 

Symptoms. — In  some  cases  there  is  a  remarkable  absence  of  symptoms. 
Convulsions  occur  in  comparatively  few  cases,  and  the  other  manifesta- 
tions of  uremia  are  equally  rare.  The  patient  may  survive  from  one  to 
two  weeks,  and  one  case  is  reported  in  which  death  did  not  occur  for 
nineteen  days. 

Treatment  depends  upon  the  cause.  Mechanical  obstruction  calls  for 
prompt  surgical  measures.  In  nonobstructive  cases,  hot  applications 
or  dry  cups  to  the  loins,  free  purgation,  and  sweating  induced  by  hot 
baths  or  pilocarpin  may  prove  effective  in  re-establishing  the  secretion. 
Pure  water  should  be  drunk  freely.  Rectal  irrigations  with  a  large 
quantity  of  hot  normal  saline  solution  has  been  employed  with  excel- 
lent result. 

Albuminuria. — The  presence  of  albumin  in  the  urine  was  formerly 
regarded  as  a  pathognomonic  sign  of  Bright's  disease — a  name  which  for 
many  years  included  all  forms  of  nephritis.  It  is  now  recognized  as  a 
symptom  common  to  many  affections,  not  of  the  kidneys  alone,  but 
of  the  blood,  blood-pressure,  the  general  system,  or  the  nervous  system. 
These  are  conveniently  grouped  under  the  two  heads  of  Albuminuria 
without  Definite  Lesions  of  the  Kidney,  and  Albuminuria  with  Definite 
Lesions  of  the  Kidney. 

Albuminuria  without  Definite  Kidney  Lesions.— (i)  Functional  Al- 
.buminuria. — The  term  physiological  albuminuria  has  also  been  applied  to 
this  form,  but  rather  unfortunately,  since  it  is  not  probable  that  albu- 
min ever  escapes  into  the  urine  independently  of  some  defect  in  the 
integrity  of  the  epithelium  of  the  glomerulus  or  of  the  tubules,  with  per- 
haps two  exceptions.  These  are,  first,  the  slight  trace  of  nucleoalbumin 
that  is  almost  constantly  recognizable  in  normal  urine  with  the  more 
delicate  tests ;  and,  second,  the  elimination  of  egg-albumen  after  it  has 
been  ingested  in  large  quantity. 

Different  names  have  been  applied  to  albuminuria  appearing  under 
different  conditions,     {a)    Cyclic^  intermittent,  and  paroxysmal  albumi- 


5s6  PRACTICE  OF  MEDICINE 

nuria  are  terms  applied  to  cases  in  which  the  presence  of  albumin  is 
intermittent,  often  following  a  regular  daily  course,  disappearing  dur- 
ing sleep,  increasing  with  activity,  or  appearing  in  a  cycle  of  twelve  to 
thirty-six  hours'  duration.  It  is  more  frequently  observed  in  boys,  often, 
according  to  Teissier,  the  offspring  of  gouty  or  arthritic  parents.  In 
some  instances  it  seems  to  be  related  to  the  ingestion  of  food.  The 
quantity  of  albumin  is  seldom  more  than  a  trace,  but  it  may  be  abun- 
dant. Hyalin  casts  are  occasionally  passed,  but  as  a  rule  albumin  is 
the  only  abnormal  ingredient.  The  specific  gravity  may  be  increased, 
and  the  color  high.  Mucin  and  the  proteids  of  semen,  the  prostatic 
secretion,  or  a  leucorrheal  discharge  should  be  carefully  excluded. 

((^)  The  alhiminuria  of  adolescence  is  closely  related  to  the  cyclic,  if 
not  identical  with  it.  It  has  been  looked  upon  in  some  instances  as  a 
persistence  of  an  embryonic  type,  since  it  has  been  shown  that  the  em- 
bryonic kidney  secretes  albuminous  urine  up  to  the  time  of  birth. 

(2)  Febrile  albuminuria  has  been  regarded  as  a  result  of  the  pyrexia, 
but  in  most  cases  it  is  doubtless  due  to  the  action  of  the  toxins  of  the 
febrile  disease.  It  is  especially  frequent  in  connection  with  diphtheria, 
typhoid  fever,  pneumonia,  and  malaria.  The  quantity  of  albumin  is  usu- 
ally slight,  but  the  urine  is  concentrated,  of  high  specific  gravity  and 
color,  and  the  urates  are  increased.  Casts  are  frequently  found.  A 
transient  cloudy  swelling  of  the  renal  epithelium  is  probably  always  pres- 
ent, but  complete  recovery  usually  occurs  spontaneously  soon  after  the 
toxic  matter  has  been  eliminated  from  the  blood. 

(3)  Hemic  albtiminiiria  depends  upon  changes  in  the  blood  which  favor 
the  transudation  of  albumin.  It  is  seen  in  profound  anemia,  pregnancy, 
syphilis,  purpura,  scurvy,  or  as  a  result  of  poisoning  with  metallic  salts, 
turpentine,  carbolic  acid,  and  the  irritant  diuretics,  and  sometimes  after 
ether  or  chloroform  narcosis. 

(4)  Neurotic  albumiriuria  is  observed  after  convulsions,  epilepsy,  or 
tetanus,  sometimes  in  exophthalmic  goiter,  cerebral  hemorrhage,  or  in- 
jury of  the  brain. 

Albuminuria  with  Definite  Kidney  Lesions.— Every  form  of  inflam- 
matory or  degenerative  disease  of  the  kidneys  is  more  or  less  constantly 
accompanied  with  albuminuria.  The  presence  of  a  large  quantity  (it 
seldom  exceeds  3  per  cent  by  weight)  is  usually  indicative  of  a  cor- 
respondingly grave  lesion;  but  the  presence  of  casts,  particularly  of 
fatty  casts,  is  of  greater  diagnostic  significance.  In  the  chronic  inter- 
stitial form,  however,  albumin  is  rarely  abundant,  and  may  be  tempora- 
rily absent. 

Tests.— The  tests  for  albumin  and  other  ingredients  of  the  urine  will 
be  found  upon  page  727   et  seq. 

Prognosis.— The  prognosis  of  albuminuria  depends  upon  its  cause. 
Much  can  be  inferred  also  from  its  persistency.  Febrile  and  cychc  albu- 
minurias are  generally  transitory,  but  they  cannot  be  regarded  as  triv- 
ial when  they  become  persistent.  Age  is  an  important  factor  in  prog- 
nosis. Albuminuria  of  moderate  degree  is  comparatively  common  in 
advanced  age,  increasing  in  frequency  after  the  fortieth  year,  and  al- 
though it  denotes  decline  and  probably  renal  degeneration,  it  is  not 
necessarily  of  serious  moment.  The  presence  of  casts  in  connection  with 
this  form  of  albuminuria  has  been  variously  estimated.     F.   C.  Shat- 


ANOMALIES  OF  RENAL  SECRETION  557 

tuck  regards  the  presence  of  a  small  quantity  of  albumin  with  small 
hyalin  and  granular  casts  in  those  past  fifty  years  as  often  of  little 
or  no  practical  importance.  Its  presence  should,  nevertheless,  arouse 
greater  care  to  relieve  the  kidneys  from  excessive  work  in  the  elimina- 
tion of  effete  matter. 

Hemoglobinuria. — Hemoglobin,  the  red  coloring  matter  of  the  blood, 
may  be  found  in  the  urine  in  either  of  its  three  forms,  but  it  is  gener- 
ally in  the  form  of  methemoglobin,  especially  when  the  urine  is  acid. 
It  is  due  to  a  dissolution  of  the  red  blood-corpuscles  (hemolysis)  and 
may  be  toxic  or  paroxysmal. 

(i)  Toxic  hemoglobinuria  sometimes  occurs  :  (ji)  In  the  more  virulent 
infections,  as  yellow  fever,  typhus,  malignant  scarlet  fever,  malaria, 
sometimes  in  syphilis;  (^)  as  a  result  of  large  doses  of  potassium 
chlorate  or  poisoning  with  pyrogallic  acid,  carbolic  acid,  arseniureted 
hydrogen,  carbon  monoxid,  muscarin,  turpentine,  and  other  drugs;  or 
(^)  such  blood-states  as  those  of  pernicious  anemia,  leukemia,  purpura, 
scurvy,  or  after  burns  or  the  transfusion  of  blood  from  a  different  animal. 
It  has  been  attributed  to  the  action  of  quinin  in  the  malarial  patient, 
or  to  the  direct  action  of  cold,  as  in  soldiers  sleeping  upon  the  ground. 
Epidemic  hemoglobinuria  is  occasionally  observed  among  the  new-born. 

(2)  Pm-oxysmal  hemoglobinuria  occurs  chiefly  in  adult  males  at  vari- 
able intervals,  often  after  exposure  to  cold  or  overexertion.  It  some- 
times occurs  in  connection  with  Raynaud's  disease.  Malarial  hemoglo- 
binuria, although  toxic,  may  be  periodic. 

Symptoms. — The  attack  frequently  comes  on  suddenly  without  recog- 
nizable cause,  or  it  may  be  preceded  by  a  chill  and  fever  and  accompanied 
with  vomiting,  diarrhea,  and  pain  in  the  lumbar  region.  Jaundice  is 
sometimes  present.  Two  or  three  paroxysms  sometimes  occur  in  a  day, 
with  intervals  in  which  clear  urine  is  voided.  The  essential  feature  is 
the  presence  of  methemoglobin,  without  corpuscles  or  coagula. 

The  prognosis  is  favorable,  except  in  connection  with  the  more  malig- 
nant diseases,  or  in  acute  poisoning. 

Treatment.— Rest  is  essential.  Dry  cups  or  other  counter-irritation 
over  the  kidneys  sometimes  arrests  an  attack.  Blisters  should  not  be 
appHed.  Hot  drinks  are  of  benefit;  stimulants  must  be  avoided.  Er- 
gotin  administered  hypodermically  is  sometimes  effective,  and  amyl  ni- 
trite is  said  to  arrest  or  cut  short  an  attack.  Quinin  should  be  given 
v/ithout  hesitation  in  malarial  cases. 

Hematuria  signifies  the  presence  of  blood  in  the  urine.  This  occurs 
in  certain  general  diseases  and  in  local  renal  conditions. 

(i)  The  general  diseases  are:  (.^)  Those  causing  profound  altera- 
tion of  the  blood,  as  pernicious  anemia,  leukemia,  purpura,  scurvy, 
malaria,  and  occasionally  other  acute  infections;  (^b}  those  causing  re- 
nal congestion,  as  the  late  stages  of  valvular  heart  disease,  interstitial 
pneumonia,  or  the  hepatic  cirrhoses. 

(2)  Local  Conditio7is.—(^a')  It  may  originate  in  the  kidney  from  in- 
tense acute  nephritis,  renal  infarction,  calculus,  tuberculosis,  pyelitis, 
parasites,  or  injury,  including  injury  of  a  floating  kidney;  (J?)  from 
injury,  calculus,  or  disease  of  a  ureter,  the  bladder,  or  urethra,  particu- 
larly from  malignant  or  tubercular  growths  or  ulceration,  gonorrhea, 
the  rupture  of  a  dilated  vein,  or  parasites.     The  term  endemic  hema- 


558  PRACTICE  OF  MEDICINE 

turia  is  applied  to  a  form  which  occurs  in  tropical  countries  as  a  result 
of  the  filaria  sanguinis  or  distoma  hematobium. 

Diagnosis. — Blood  in  the  urine  is  recognized  by  the  color,  ranging 
from  a  smoky  hue  to  a  dark  brown  or  black,  often  by  the  presence  of 
clots,  and  by  the  reactions  of  albumin  and  the  discovery  of  corpus- 
cles on  microscopic  examination.  Blood-casts  are  found  in  renal  hema- 
turia. 

Hematoporphyrinuria.— Hematoporphyrin,  iron-free  hematin,  some- 
times appears  in  the  urine  in  connection  with  several  diseases,  especiall}^ 
tuberculosis,  leprosy,  pneumonia,  pleurisy,  and  hepatic  cirrhosis,  or  after 
prolonged  use  of  sulphonal  or  trional.  The  urine  is  dark  and  concen- 
trated. 

Albumosuria  occurs  during  many  febrile  conditions,  in  chronic  suppu- 
ration and  in  connection  with  neoplasms  or  syphilis  of  bone,  especially 
in  the  myelomata.  The  urine  is  often  turbid.  The  precipitate  formed 
by  the  addition  of  nitric  acid  is  dissolved  by  heat,  and  again  thrown 
down  upon  cooling.  The  reaction  is  often  referred  to  as  the  Bence  Jones 
reaction. 

Globulin  appears  in  the  urine  generally,  if  not  exclusively,  in  connec- 
tion wdth  albumin,  and  it  often  exceeds  the  latter  in  quantity.  Its- 
significance  is  the  same  as  that  of  albumin,  except  that  it  is  more  ex- 
clusively present  in  acute  parenchymatous  nephritis  and  amyloid  degen- 
eration of  the  kidneys. 

Chyluria. — This  symptom  has  been  referred  to  in  connection  with  the- 
filaria  sanguinis,  but  it  occasionally  occurs  independently  of  the  pres- 
ence of  parasites.  The  urine  has  a  milky  appearance  due  to  the  ad- 
mixture of  fat-globules,  or  it  may  be  pink  from  the  presence  of  blood. 
Spontaneous  coagulation  sometimes  occurs  upon  cooling.  Nonparasitic 
chyluria  is  generally  attributed  to  an  accidental  communication  be- 
tween a  lymph-vessel  and  some  part  of  the  urinary  tract. 

Pyuria. — Pus  is  found  in  the  urine  in  variable  quantity  in  connection 
with  all  suppurative  affections  of  the  urinary  passages.  It  may  also 
enter  the  urine  from  other  sources,  as  by  the  rupture  of  pelvic  or  other 
abscesses  into  the  urinary  passages.  The  conditions  with  which  it  is 
generally  associated  are  :  («;)  Pyelitis,  pyonephritis,  pyonephrosis,  and 
cystitis;  (/;)  gonorrheal  urethritis,  leucorrhea,  and  prostatic  abscess;, 
and  (r)  rupture  of  a  pelvic,  perityphlitic,  or  perinephric  abscess  into 
the  passages. 

Lithuria. — Uric  acid  is  found  in  excess,  usually  in  the  form  of  sodium 
or  ammonium  urates,  chiefly  in  connection  with  gout  or  in  the  condi- 
tions described  as  lithemia.  The  urates  are  deposited  in  the  form  of  crys- 
tals or  as  amorphous,  "brick-dust"  sediment;  but  it  is  only  when  the 
deposit  is  excessive  that  it  is  of  importance,  since  a  small  deposit  is  nor- 
mal after  the  urine  becomes  cold.  An  increased  elimination  of  Uric  acid 
constantly  follows  excessive  ingestion  of  proteid  food.  Quite  a  number 
of  morbid  conditions  involving  every  vital  system  have  been  attributed 
to  lithemia,  and  all  are  grouped  by  many  writers  under  the  head  of  the 
lithemic  diathesis.  There  is,  however,  very  Httle  positive  knowledge  of 
the  pathology  of  the  conditions.  Excessive  eating  and  drinking,  with 
deficient  muscular  exercise,  are  essential  factors  in  the  production  of  gout, 
a  closely  allied  affection.    Deficient  oxidation  is  probably  the  important 


ANOMALIES  OF  RENAL  SECRETION  559 

element  in  the  faulty  metabolism  of  both  affections.  In  gout,  the  urates 
are  deposited  about  the  joints,  while  in  lithemia  they  are  eliminated 
in  excessive  quantity.  High  arterial  tension,  with  a  tendency  to  degen- 
erative changes  in  various  tissues,  is  also  common  to  both  conditions. 

Phosphaturia. — An  increased  elimination  of  phosphates  occurs  in  ex- 
tensive destructive  lesions  of  bone,  as  rickets,  osteomalacia,  and  tuber- 
culosis, in  acute  yellow  atrophy  and  cirrhosis  of  the  liver,  pernicious 
anemia,  leukemia,  and  in  diseases  affecting  the  nerve-centers.  It  some- 
times occurs  in  flatulent  dyspepsia  or  simply  as  a  result  of  the  ingestion 
of  food  rich  in  phosphates,  and  cases  are  sometimes  met  with  in  which 
an  extremely  large  quantity  is  more  or  less  constantly  discharged  with- 
out recognizable  cause  further  than  a  decomposition  of  the  urine  within 
the  bladder.  The  phosphates  are  usually  deposited  in  the  form  of  cal- 
cium or  magnesium  phosphates,  or  of  ammonium-magnesium  phosphates, 
the  so-called  triple  phosphates.  The  term  phosphatic  diabetes  has  been 
applied  to  an  excessive  elimination  of  phosphates  with  polyuria,  ab- 
normal appetite,  emaciation,  furunculosis,  and  other  symptoms  resem- 
bling diabetes.  Sugar  has  sometimes  been  found  in  the  urine  of  these 
cases.  The  phosphates  may  be  deposited  from  the  urine  as  a  result  of 
decomposition  due  to  cystitis  or  other  causes,  when  they  are  not  exces- 
sive in  quantity. 

Oxaluria. — A  small  quantity  of  oxalic  acid  is  normally  an  ingredient 
of  the  urine  in  the  form  of  calcium  oxalate,  being  a  derivative  of  the 
acid  entering  the  system  in  fruit  and  vegetables.  An  excessive  elimina- 
tion occurs  for  the  most  part  as  a  result  of  the  ingestion  of  such  articles 
as  tomatoes,  turnips,  onions,  apples,  and  pears.  It  not  infrequently 
occurs  also  in  the  presence  of  gastric  or  intestinal  indigestion,  particu- 
larly when  free  hydrochloric  acid  is  absent  from  the  gastric  juice.  Rarely 
an  excessive  formation  of  the  calcium-oxalate  crystals  within  the  urinary 
passages  leads  to  the  formation  of  calculi.  Acid  fermentation  of  mucus 
in  the  bladder  is  believed  to  produce  oxaluria  in  some  cases.  Various 
nervous  manifestations,  especially  hypochondriasis,  neurasthenia,  and 
less  pronounced  mental  depression  or  languor  are  sometimes  associated 
with  oxaluria.  Albuminuria  is  sometimes  induced  apparently  by  the 
irritation  of  the  urinary  passages  by  the  minute  crystals. 

Cystinuria  is  a  rare  condition  of  the  urine,  usually  associated  witb 
jaundice  due  to  hepatic  disease.  A  family  tendency  to  the  condition 
has  been  observed.  Its  chief  importance  lies  in  the  fact  that  cystin 
sometimes  forms  the  nucleus  of  a  calculus. 

Indicanuria. — Indican  or  potassium  indoxylsulphate  is  recognized  in 
the  urine  only  upon  the  addition  of  strong  acid,  by  which  it  is  oxidized 
into  indigo.  It  is  regarded  as  a  derivative  of  indol  formed  in  the  intes- 
tine by  bacterial  decomposition  of  proteid,  especially  in  cases  of  ob- 
struction, chronic  peritonitis,  wasting  diseases,  or  carcinoma. 

Melanuria  is  usually  associated  with  melanotic  sarcoma.  The  urine 
acquires  a  dark  color  from  the  presence  of  pigment  in  solution  or  in 
granular  form.  In  some  instances,  before  melanin  appears,  the  urine  is 
found  to  acquire  a  dark  color  after  standing,  from  the  presence  of  me- 
lanogen. 

Alkaptonuria. — This  condition,  in  which  alkapton  is  found  in  the  urine, 
may  be  of  long  duration,  occurring  at  longer  or  shorter  intervals  for 


56o      •  PRACTICE  OF  MEDICINE 

many  years,  and  at  any  period  of  life.  Several  members  of  a  family 
may  be  affected.  It  is  increased  by  meat  diet,  and  in  some  cases  of  tu- 
berculosis. The  reaction  has  been  attributed  by  different  writers  to 
uroleucinic,  uroxanthic,  or  homogentisinic  acid.  Some  regard  it  as  due 
to  intestinal  decomposition  in  some  manner  affecting  the  tyrosin  nor- 
mally present,  since  it  has  been  found  that  the  administration  of  tyrosin 
to  the  alkapton  patient  increases  the  quantity  ehminated.  The  admin- 
istration of  intestinal  antiseptics  does  not  arrest  the  excretion. 

Lipuria,  in  which  molecular  or  crystalline  fat  appears  in  the  urine, 
may  result  from  the  excessive  ingestion  of  fat,  as  codliver  oil,  and  it 
may  occur  in  such  affections  as  diabetes,  chronic  diffuse  nephritis,  chronic 
suppuration,  fat-embolism  from  fracture  of  bone,  chyluria,  and  phos- 
phorus-poisoning.   The  urine  becomes  milky  in  extreme  cases. 

Lipaciduria  is  a  terra  applied  to  a  condition  in  which  the  urine  con- 
tains fatty  acids,  acetic,  butyric,  formic,  or  propionic.  It  has  been  ob- 
served after  the  eating  of  a  large  quantity  of  fat,  and  sometimes  in  con- 
nection with  nephritis. 

Diaceturia  signifies  the  elimination  of  ethyldiacetic  acid  in  the  urine. 
It  is  generally  observed  in  the  acute  infectious  diseases  or  in  diabetes. 
In  the  latter  connection  it  frequently  indicates  the  approach  of  coma. 
Oxybutyric  acid  sometimes  accompanies  the  diacetic  acid  in  diabetes. 

Pneumaturia  denotes  the  passage  of  gas  from  the  urethra  after  the 
discharge  of  urine.  It  is  due  to  the  decomposition  of  the  urine  by  gas- 
forming  bacteria  or  to  the  entrance  of  gas  from  the  bowel  through  a 
fistula.  Air  may  enter  also  during  catheterization  or  cystoscopic  exami- 
nation, to  escape  at  the  next  urination.  The  diagnosis  can  be  estab- 
lished by  catheterizing  the  patient  with  the  end  of  the  catheter  held 
under  the  surface  of  water. 


UREMIA. 

Def/n/t/on. — A  form  of  autointoxication  which  generally  occurs  in  acute 
or  chronic  nephritis  or  in  conditions  attended  with  anuria.  The  nature 
of  the  toxic  substance  is  not  known ;  urea  is  no  longer  regarded  as  the 
sole  cause  of  the  condition.  Several  theories  are  entertained  in  regard 
to  the  nature  and  cause  of  the  condition. 

Theories  of  Uremia. — (i)  The  most  commonly  accepted  view  is  that 
the  intoxication  is  due  to  the  retention  of  one  or  probably  several  nitrog- 
enous exa-ementitions  substances.  The  relation  of  urea,  uric  acid,  and 
the  urates  to  the  condition  is  no  longer  looked  upon  as  an  important 
one.  Other  members  of  the  same  group  are  probably  of  greater  activity. 
The  blood-serum  becomes  highly  toxic  during  the  paroxysms;  all  are 
not  agreed,  however,  as  to  whether  this  toxicity  is  due  to  the  retention 
of  poisons  normally  present  or  to  the  production  of  new  toxic  matter. 

(2)  Brown-Seqimrd^s^ theory  refers  the  toxemia  to  an  undemonstrated 
internal  secretion  of  the  kidney,  similar  to  that  of  the  thyroid  gland 
or  suprarenal  bodies. 

(3)  Traicbe's  theory  attributes  the  symptoms  to  edema  of  the  brain. 

(4)  Delafield  regards  the  motor  symptoms  as  due  to  contraction  of 
the  arteries  by  some  other  influence  than  toxemia. 


UREMIA  561 

Symptoms. — Uremia  may  be  acute  or  chronic.  To  these  forms  is  added 
by  some  authors  a  third,  a  latent  form,  supposed  to  exist  in  cases  of 
anuria. 

Acute  Uremia. — The  onset  may  be  sudden  and  severe  or  gradual, 
with  symptoms  of  the  same  character,  but  of  less  severity.  The  attack 
may  develop  in  the  course  of  any  form  of  nephritis,  but  more  particu- 
larly in  an  acute  nephritis  due  to  an  infectious  disease.  The  prominent 
symptoms  are  headache,  vomiting-,  dyspnea,  convulsions,  and  delirium 
or  coma,  (^a^  The  headache  is  generally  occipital,  extending  to  the  neck, 
and  intensely  severe.  It  is  often  attended  with  vertigo  and  deafness. 
(Ji)  Vomiting  is  often  the  first  manifestation  and  sometimes  the  only 
one.  Its  chief  characteristic  is  its  persistency,  occasionally  leading  to 
death  from  exhaustion.  It  may  be  preceded  by  intense  nausea  and 
accompanied  with  profuse  diarrhea.  In  some  instances  the  diarrhea 
develops  without  vomiting.  A  membranous  colitis  is  sometimes  found 
after  death,  (r)  Dyspnea  may  be  constant  or  paroxysmal,  and  occurs 
more  particularly  during  the  night.  The  patient  must  sit  up  as  in 
asthma,  and  this  often  adds  to  his  suffering  by  aggravating  the  edema 
of  the  lower  extremities,  when  this  is  present.  Restlessness  is  often  de- 
veloped. The  lungs  may  be  free  from  adventitious  signs,  but  there  is 
great  danger  of  pulmonary  edema,  especially  in  the  parenchymatous 
forms  of  nephritis.  Cheyne-Stokes  respiration  is  often  observed,  and  the 
patient  may  become  deeply  cyanotic,  the  extremities  blue  and  cold  during 
the  temporary  cessation  of  breathing.  (^)  Fever  is  present  in  some  cases, 
but  it  is  usually  slight  until  immediately  before  death,  when  the  tem- 
perature may  rapidly  rise.  The  pulse  is  variable,  usually  full  and  bound- 
ing, but  later  becoming  feeble  and  threadlike.  It  is  not  usually  very 
rapid,  (je^  Convulsions  sometimes  develop  toward  the  close.  For  days 
before  the  appearance  of  a  distinct  convulsion,  however,  there  is  often 
a  more  or  less  constant  twitching  of  the  muscles  of  the  face  and  fingers. 
The  convulsions  are  epileptic  in  character,  either  local  or  general,  usu- 
ally unattended  with  outcry.  The  patient  generally  becomes  comatose 
before  the  seizure,  and  remains  in  this  state  between  the  attacks,  which 
may  recur  as  often  as  every  hour  or  two.  Hemiplegia  or  monoplegia 
may  develop  before  or  during  the  convulsion,  and  blindness  or  deafness 
often  remains  for  a  short  period  in  cases  that  recover.  General  edema  of 
the  brain  is  often  the  only  morbid  condition  found  after  death,  aside 
from  the  kidney  lesions.  (/)  Delirium  develops  in  some  cases.  It  may 
be  mild  and  muttering,  or  it  may  assume  the  form  of  \aolent,  even  sui- 
cidal mania.  (^)  Coma  with  stertorous  breathing  may  precede  or  fol- 
low the  delirium.  The  condition  is  usually  rapidh^  {3Xs\\  it  may,  how- 
ever, subside  into  a  chronic  state  or  the  uremic  manifestations  may  en- 
tirely subside.  Acute  attacks  not  infrequently  supervene  upon  the  chronic 
form  of  the  condition. 

Chronic  Uremia. — A  chronic  uremic  condition  is  more  commonly  as- 
sociated with  arteriosclerosis  or  chronic  interstitial  nephritis  than  with 
the  parenchymatous  forms  of  kidney  disease.  The  symptoms  are  the 
same  in  character,  but  less  violent  than  those  belonging  to  the  acute 
form.  Acute  exacerbations  are  not  unusual  during  the  course  of  chronic 
uremia.  The  headache  is  persistent,  usually  occipital,  sometimes  frontal. 
The  dyspnea  is  more  or  less  constant,  and  the  Chevne-Stokes  breathing 
36 


562  PRACTICE  OF  MEDICINE 

may  develop  during  sleep.  Insomnia  is  often  a  troublesome  symptom, 
however,  independently  of  other  conditions.  Gastrointestinal  disturb- 
ances occur  periodically.  A  persistent  catarrhal  or  mycotic  stomatitis 
often  develops,  with  swelling  of  the  tongue  and  gums,  and  intensely  foul 
breath.  The  tongue  is  heavily  coated,  brown  and  dry.  Nausea,  vomit- 
ing, and  diarrhea  are  more  or  less  frequently  present.  Cramping  in  the 
leg  muscles  and  dryness  of  the  skin,  with  pruritus,  are  often  exceedingly 
annoying  complications.  These  manifestations  frequently  persist  for 
years,  becoming  at  times  more  pronounced  or  developing  into  an  acute 
uremia  with  delirium  or  hallucinations,  and  finally  terminating  in  coma 
or  convulsions,  or  by  the  development  of  a  technical  infection  of  the 
endocardium,  or  more  frequently  of  one  of  the  serous  membranes,  the 
pericardium,  pleura,  peritoneum,  or  meninges. 

Diagnosis. — The  early  symptoms  of  uremia  are  readily  recognized,  as 
a  rule,  upon  thorough  examination.  Routine  examination  of  the  urine 
is  the  best  safeguard  against  error.  The  urine  should  invariably  be  ex- 
amined chemically  and  microscopically  in  a  case  of  persistent  headache, 
nausea,  vomiting,  diarrhea,  and  even  when  persistent  muscular  cramps  or 
supposed  neuralgic  pains  are  complained  of.  The  diagnosis  is  most  dif- 
ficult when  the  case  is  seen  for  the  first  time  during  coma.  The  conditions 
most  likely  to  enter  into  the  differentiation  are  diabetic  or  alcoholic 
coma,  unconsciousness  due  to  cerebral  hemorrhage  or  opium-poisoning. 
When  the  comatose  condition  becomes  protracted,  it  may  simulate  the 
stupor  of  typhoid  fever,  miliary  tuberculosis,  meningitis,  or  other  infec- 
tious disease. 

Diabetic  coma  comes  on  suddenly,  without  premonitory  symptoms, 
and  it  is  not  accompanied  with  convulsive  manifestations;  the  odor  of 
the  breath  is  sweetish  or  fruitlike,  not  fetid,  and  the  arterial  tension  is 
usually  normal  and  not  increased.  The  bladder  generally  contains  a 
considerable  quantity  of  urine  rich  in  sugar. 

Cerebral  hemorrhage  is  characterized  by  sudden  onset,  complete  hemi- 
plegia, irregular  pupils,  and  conjugate  deviation  of  the  eyes.  The  breath 
has  no  distinctive  odor,  the  arteries  are  usually  atheromatous,  the 
urine  may  be  normal,  and  the  reflexes  are  exaggerated  on  the  affected 
side.  A  distinct  convulsion  is  unusual.  A  brain-tumor  sometimes  causes 
confusion,  but,  as  a  rule,  the  comatose  condition  is  preceded  by  a  con- 
siderable period  during  which  more  or  less  typical  localizing  symptoms 
are  observed.  Meningitis  may  be  excluded  with  difficulty  in  some  cases. 
As  a  rule,  however,  it  is  not  accompanied  with  persistent  vomiting, 
and  constipation  is  the  rule.  The  neck  is  retracted,  and  the  pain  occa- 
sioned by  forcibly  moving  the  head  or  extremities  may  be  indicated 
by  the  patient,  even  in  coma. 

In  alcoholic  coma  the  onset  is  gradual  and  the  patient  can  be  par- 
tially aroused ;  the  breath  has  a  strong  odor  of  alcohol ;  the  pupils  are 
usually  dilated.  The  urine  may  be  normal.  Vomiting  and  muttering 
are  not  uncommon,  but  convulsions  seldom  occur. 

In  opium-poisoning  the  onset  is  slow;  the  pupils  are  extremely  con- 
tracted; the  respiration  is  slow,  sometimes  less  than  ten  in  the  minute, 
and  often  irregular.  The  skin  is  cold  and  pale  or  cyanotic.  The  heart's 
action  becomes  feeble.  There  is  usually  little  urine  in  the  bladder,  but 
its  reactions  are  normal,  except  for  the  presence  of  morphin.    If  a  liquid 


ACUTE   NEPHRITIS  563 

preparation  of  opium  has  been  drunk,  its  odor  may  be  detected  on  the 
breath. 

A  form  of  coma  which  is  probably  closely  related  to  uremia  is  occa- 
sionally encountered  as  a  result  of  prolonged  violent  muscular  exertion. 
The  urine  may  be  albuminous,  but  the  nature  of  the  condition  is  re- 
vealed by  the  history,  as  when  it  develops  upon  a  long  bicycle  tour. 
The  unconsciousness  due  to  heat  prostration  can  generally  be  recognized 
from  the  history  as  well  as  by  the  high  temperature. 

Prognosis. — The  prognosis  is  exceedingly  unfavorable,  especially  in 
advanced  arteriosclerosis  or  chronic  interstitial  nephritis,  and  when 
the  uremia  occurs  in  an  alcoholic  subject.  Recovery  may  take  place, 
however,  in  apparently  extremely  unfavorable  cases. 

The  treatment  is  considered  in  connection  with  the  treatment  of  chronic 
interstitial  nephritis. 


ACUTE  NEPHRITIS. 

ACUTE   DIFFUSE,   PARENCHYMATOUS,   EXUDATIVE,  DESQUAMATIVE,  CROUP- 
OUS,  OR  CATARRHAL  NEPHRITIS;  ACUTE 
BRIGHT'S    DISEASE. 

Definition. — An  acute  inflammation  involving  to  a  variable  extent  both 
the  parenchyma  and  interstitial  structures  of  the  kidneys. 

Etiology. — The  disease  may  occur  at  any  period  of  life,  but  it  is  some- 
what more  frequent  in  the  young  than  after  middle-life.  Men  are  more 
commonly  affected,  probably  because  of  greater  exposure ;  among  chil- 
dren, both  sexes  are  affected.  Alcoholism  increases  susceptibility,  if  in 
no  other  way,  by  increasing  exposure. 

The  exciting  causes  are:  (i)  Lifluences  acting  upon  the  skin,  especially 
cold  and  wet.  Exposure  probably  also  increases  the  susceptibility  of 
the  patient  to  the  action  of  toxic  matter  upon  the  kidneys.  Chronic 
skin  diseases,  burns,  and  other  injuries  may  be  followed  by  an  acute 
nephritis. 

(2)  Biological  Toxic  Agents. — The  specific  poisons  of  the  acute  infec- 
tious diseases,  especially  of  scarlet  fever,  but  to  a  less  extent  of  the  other 
exanthemata,  diphtheria,  typhoid  fever,  malaria,  yellow  fever,  and  dys- 
entery. Syphilis  and  tuberculosis  often  bear  a  more  or  less  close  etio- 
logical relation.  The  disease  may  develop  in  connection  with  purpura 
and  other  blood-states,  septicemia,  rheumatism,  or  erysipelas. 

(3)  Chemical  toxic  agents,  turpentine,  cantharides,  carbolic  acid,  po- 
tassium chlorate,  possibly  lead,  arserift:,  and  phosphorus,  may  induce  the 
disease. 

(4)  Pregnancy .—T\{\'=,  usually  develops  in  primipara  toward  the  close 
of  gestation.  Whether  it  is  due  to  interference  with  the  circulation 
through  pressure,  an  altered  blood-state,  or  the  presence  of  unrecognized 
toxic  substances,  is  not  known.  Acute  nephritis  may  develop  after  sur- 
gical operations  on  the  kidneys,  and  it  is  often  a  complication  of  chronic 
nephritis  due  to  increase  of  the  inflammation. 

Morbid  Anatomy.— The  post-mortem  appearances  are  not  constant. 
In  a  majority  of  cases  the  kidneys  are  normal  in  size,   or  slightly  en- 


564  PRACTICE  OF  MEDICINE 

larged,  and  intensely  hyperemic.  Both  organs  are  equally  affected. 
The  capsule  strips  off  normally,  but  the  denuded  surface  is  mottled,  the 
larger  hyperemic  areas  including  normal  or  anemic  patches.  The  cut 
surface  bleeds.  In  some  cases,  however,  all  evidences  of  hyperemia  are 
absent  and  the  kidneys  may  be  abnormally  pale.  The  medullary  por- 
tion is  generally  more  deeply  congested  than  the  cortical.  In  some 
instances  the  glomeruli  are  prominent  and  congested,  in  others  they  are 
pale.  On  microscopic  examination  the  lesions  may  be  found  almost 
exclusively  confined  to  the  tufts  and  the  convoluted  tubules.  The 
changes  may  involve  chiefly  the  capillaries  or  the  epithelium.  In  the 
former,  there  is  more  or  less  extensive  obstruction  by  cells  and  thrombi; 
in  the  latter  there  are  cloudy  swelling,  proliferation,  and  desquamation 
of  the  epithelium.  Hyalin  and  fatty  degeneration  are  seen  in  the  cells 
of  the  convoluted  tubules,  especially  in  toxic  cases.  Hyalin  degeneration 
sometimes  affects  also  the  contents  of  the  blood-vessels  and  tubules 
after  obstruction.  In  severe  cases  an  exudation  of  serum  with  a  greater 
or  less  number  of  red  and  white  blood-cells  is  found  between  the  tubules 
(acute  exudative  nephritis  of  Delafield).  The  changes  in  other  organs 
are  seen  chiefly  in  the  serous  membranes.  All  the  serous  cavities  as  a 
rule  contain  an  increased  quantity  of  fluid.  A  form  of  acute  nephritis 
usually  met  with  in  children  has  been  described  by  Councilman,  in  which 
the  cells  resemble  plasma-cells,  and  are  possibly  derived  from  other 
sources,  as  the  spleen  and  bone-marrow,  and  are  brought  to  the  kidneys 
in  the  blood. 

Symptoms. — The  symptoms  develop  suddenly  or  gradually.  (^7)  A 
sudden  onset  is  common  after  exposure  to  cold  or  as  a  result  of  the 
rapid  accumulation  of  toxic  matter.  It  is  usually  marked  by  a  chill 
with  moderate  fever,,  drowsiness,  pain  in  the  loins,  and  prostration. 
The  urine  is  diminished  in  quantity,  dark,  of  high  specific  gravity,  and 
contains  much  albumin,  hyalin,  epithelial,  and  blood-casts,  often  blood- 
corpuscles.  Edema  of  the  face  and  extremities  is  usually  developed  early, 
and  in  severe  cases,  headache,  nausea,  vomiting,  and  delirium  or  coma 
set  in  as  uremia  approaches.  (/;}  A  gradual  onset  is  often  observed 
after  a  febrile  disease.  The  patient  becomes  anemic,  the  eyelids  puffy, 
and  other  manifestations  of  dropsy  ensue.  The  urine  becomes  scanty, 
dark,  and  concentrated,,  and  albumin  and  casts  are  found  in  it.  Head- 
ache, nausea,  and  vomiting  may  follow,  and  the  bowels  are  irregular. 
Muscular  weakness  is  complained  of,  and  dyspnea  follows  sHght  exertion. 
Fever  is  not  generally  present,  but  the  skin  is  dry.  The  symptoms  may 
subside,  or  they  may  at  any  time  give  place  to  a  sudden  uremic  explo- 
sion, \vith  more  or  less  rapidly  fatal  termination.  The  disease  occasion- 
ally passes  into  a  chronic  form. 

Special  Symptoms. — The  urine  may  be  reduced  to  four  or  five  ounces  in 
twenty-four  hours,  the  specific  gravity  increased  to  1.025,  1.030,  or 
higher;  the  color  is  dark,  often  turbid,  and  it  may  be  smoky  from  ad- 
mixture of  blood.  The  albumin  in  it  rarely  exceeds  i  per  cent.  The 
urea,  chlorids,  and  phosphates  are  diminished.  The  casts  appear  early 
ia  many  cases,  and  persist  after  the  albumin  has  ceased  to  be  found. 
Epithelial  cells  in  a  state  of  fatty  degeneration,  leucocytes,  and  granular 
detritus  are  usually  present,  and  especially  abundant  in  scarlatinal  cases. 

Edema  appears  first  in  the  eyelids,  ankles,  and  hands,  and,  when  the 


ACUTE  NEPHRITIS  565 

patient  is  confined  to  bed,  the  dependent  portions  of  the  body,  as  the 
loins  and  side  of  the  face,  become  extremely  puffed.  A  Httle  later  the 
edema  becomes  more  general.  The  loose  skin  of  the  penis  and  scrotum 
is  often  greatly  distended.  In  extreme  cases  the  eyes  are  nearly  closed, 
and  the  skin  over  the  extremities  pits  deeply  upon  pressure.  Finally, 
the  lungs  may  become  edematous,  and  the  brain  may  also  be  affected. 
Edema  of  the  glottis  occasionally  supervenes.  Gastrointestinal  symp- 
toms are  prominent  in  some  cases,  or  they  may  be  absent  until  the 
system  reaches  the  degree  of  intoxication  which  characterizes  uremia. 

Nervous  Symptonis. — Headache,  somnolency  or  insomnia,  and  delirium 
are  manifestations  of  intense  intoxication  bordering  on  uremia,  but 
they  are  not  uncommon  in  children,  and  may  completely  subside  with 
the  infection  upon  which  the  disease  depends. 

The  blood  is  hydremic.  Its  specific  gravity  may  be  reduced  a  half, 
and  the  serum  albumin  20  per  cent.  The  red  corpuscles  are  diminished, 
but  leucocytosis  is  not  present.  The  arterial  tension  is  high,  and  the 
second  sound  at  the  base  of  the  heart  is  intensified. 

Diagnosis. — The  disease  is  readily  recognized  in  well-marked  cases, 
yet  the  condition  may  be  obscure.  The  importance  of  routine  examina- 
tion of  the  urine  is  again  apparent.  The  urine  should  be  occasionally 
investigated  in  all  cases  of  acute  infectious  disease,  and  during  the  later 
months  of  pregnancy.  If  this  were  always  done,  fewer  cases  of  unsus- 
pected convulsions  or  coma  would  be  encountered. 

In  febrile  albumimirza,  violent  manifestations  are  seldom  met  with, 
and  the  urinary  changes  are  less  pronounced.  The  albumin  may  not 
exceed  a  trace,  and  blood  is  seldom  present. 

The  symptoms  of  an  acute  nephritis  occurring  during  the  course  of 
chronic  nephritis  can  be  recognized,  as  a  rule,  by  the  coexistence  of 
cardiac  hypertrophy,  great  arterial  tension,  possibly  retinitis.  The 
anemia  is  more  pronounced.  Blood-casts  are  not  found  in  the  urine, 
but  epithelial  and  fatty  casts  may  be  present,  the  latter  more  particu- 
larly in  advanced  cases. 

The  prognosis  depends  upon  the  cause  of  the  condition,  and  to  some 
extent  upon  the  age  of  the  patient.  Scarlatinal  nephritis  in  very  young 
children  is  often  fatal.  In  older  persons,  and  when  due  to  exposure, 
recovery  is  the  rule.  Extreme  dropsy,  convulsions,  coma,  great  cardiac 
weakness,  and  marked  suppression  of  the  urine  are  bad  indications. 
Recovery  is  usually  well  established  within  a  month,  if  at  all. 

Treatment. — The  success  of  treatment  depends  for  the  most  part  upon 
the  extent  to  which  the  kidneys  can  be  given  rest.  To  this  end  they 
should  be  as  far  as  possible  relieved  of  their  function  by  the  adoption 
of  a  diet  which  yields  the  least  waste,  the  cessation  of  muscular  exer- 
cise, confinement  to  bed,  and  the  substitution  of  the  action  of  the  skin 
and  bowels  for  that  of  the  kidneys.  The  best  diet  is  milk,  and  in  addi- 
tion to  it  as  much  water  as  can  be  drunk  should  be  taken,  both  for  its 
diuretic  properties,  and  for  the  purpose  of  diluting  the  toxic  matter, 
which  must  be  carried  ofT  through  the  kidneys.  Pure  buttermilk,  gruels, 
chicken  broth,  lemonade,  and  mineral  water  may  also  be  taken.  An  ex- 
cellent drink  is  made  by  the  addition  of  a  dram  of  cream  of  tartar 
and  the  juice  of  a  lemon,  with  sufficient  sugar  to  a  pint  of  water.  A 
pitcher  containing  this  solution  may  be  kept  at  the  bedside. 


566  PRACTICE  OF  MEDICINE 

The  action  of  the  skin  is  best  stimulated  by  heat.  The  patient  should 
be  kept  as  warm  as  possible,  and  urged  to  submit  to  more  than  an 
agreeable  degree  of  warmth.  A  flannel  gown  should  be  worn.  The  room 
should  be  kept  at  an  even  temperature,  and  well  ventilated.  Hot-air 
or  hot-water  baths  should  be  administered  daily  or  as  often  as  the 
strength  of  the  patient  will  permit.  Bathing  must  be  practiced,  however, 
with  the  utmost  precautions  against  subsequent  chilling.  The  patient 
must  be  removed  from  the  bath  directly  to  the  bed,  wrapped  in  a 
blanket  and  well  covered  in  order  to  promote  sweating  for  at  least  an 
hour.  The  hot-air  bath  is  often  the  safest  and  requires  no  exertion  oh 
the  part  of  the  patient.  It  may  be  administered  by  passing  hot  air 
from  an  ordinary  lamp  through  an  improvised  tube  (or  rain-spout)  with 
a  funnel-like  opening  into  the  bed,  after  having  raised  the  clothing  upon 
hoops  arched  over  the  patient.  Diuretics  should  not  be  given  until 
the  acute  manifestations  have  disappeared.  The  administration  of  digi- 
talis and  sodium-theobromin  salicylate  (diuretin)  acts  beneficially  in 
some  cases.  The  more  irritating  diuretics  should  not  be  employed  under 
any  circumstances,  and  many  cases  recover  completely  without  medica- 
tion. Pilocarpin  is  objected  to  by  many  writers  on  account  of  its  de- 
pressing effects.  Yet  in  many  cases  its  action  is  remarkable  and  en- 
tirely free  from  depression.  It  should  always  be  used  with  caution. 
The  first  dose  to  an  adult  should  not  exceed  gr.  1-12  (0.005)  hypo- 
dermically.  Afterward  the  quantity  may  be  doubled.  A  child  of  ten 
years  should  not  receive  more  than  gr.  1-24  (0.002)  as  an  initial  dose. 
The  bowels  should  be  kept  freely  active.  In  case  the  edema  fails  to  sub- 
side after  repeated  sweating,  a  robust  patient  should  receive  a  saline 
purge  every  morning  or  every  second  morning.  Magnesium  sulphate  in 
concentrated  solution  or  the  compound  jalap  powder  is  generally  most 
reliable.  The  effervescent  magnesium-citrate  solution  is  more  pleasant 
for  children.  When,  however,  the  edema  is  not  urgent,  purgation  is  not 
necessary.  The  skin  must  sometimes  be  punctured  in  order  to  prevent 
its  rupture  from  overdistention  with  fluid.  It  should  be  done  only  when 
it  is  unavoidable,  since  under  the  most  careful  precaution  an  opportu- 
nity is  afforded  for  infection.  In  practice,  however,  such  infection  is  not 
common.  The  simple  puncture  of  the  skin  with  a  sterilized  needle  after 
disinfection  is  usually  sufficient,  but  a  Southey  or  other  tube  may  be 
permitted  to  remain. 

Special  symptoms  sometimes  require  treatment.  When  the  vomiting 
is  persistent,  the  free  ingestion  of  liquids  must  be  discontinued.  Chipped 
ice  relieves  the  thirst  and  often  checks  the  vomiting.  The  required  fluid 
may  be  introduced  through  the  rectum.  Prolonged  irrigation  of  the 
large  bowel  through  the  long  rectal  tube  is  an  excellent  means  also  of 
stimulating  the  action  of  the  kidneys.  Dilute  hydrocyanic  acid,  creosot, 
or  carbolic  acid  often  allays  the  vomiting.  The  anemia  should  be  coun- 
teracted with  iron.  The  only  means  of  combating  the  albuminuria  is 
by  the  relief  of  the  renal  engorgement  through  the  measures  already  sug- 
gested, and  by  restoration  of  the  blood  to  its  normal  condition.  High 
arterial  tension,  particularly  when  it  is  associated  with  muscular  twitch- 
ings,  is  often  a  premonitory  indication  of  uremia.  It  can  sometimes  be 
reduced  with  a  few  doses  of  glonoin.  Digitalis  should  be  avoided  in 
this  condition. 


CHRONIC  NEPHRITIS  567 

During  convalescence  the  diet  must  be  gradually  added  to.  Farina- 
cious  food  should  be  allowed  for  a  considerable  time  before  nitrogenous 
articles  are  added  to  the  fare.  The  patient  should  not  be  allowed  to 
leave  the  house,  until  after  full  recovery,  unless  the  weather  is  warm. 

CHRONIC  NEPHRITIS. 

The  pathological  process  in  all  forms  of  chronic  nephritis  is  a  diffuse 
one,  affecting  both  the  parenchyma  (^i.e.,  the  glomeruli  and  the  epi- 
thelium) and  the  interstitial  connective  tissue.  When  the  later  stages 
of  the  disease  are  taken  into  consideration,  two  very  different  condi- 
tions must  be  recognized.  These  are  designated  by  Delafield,  from  the 
pathological  standpoint,  (^)  the  chronic  diffuse  nephritis  with  exudation, 
and  Qf)  chronic  productive  diffuse  nephritis  without  exudation.  The 
former  is  known  also  as  the  large  or  small  white  kidney,  and  the 
latter  as  the  granular,  sclerotic,  or  contracted  kidney.  Clinically  the 
two  forms  are  designated  as  chronic  parenchymatous  nephritis,  and 
chronic  interstitial  nephritis. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Chronic  Diffuse  or  Desquamative  Nephritis,  Chronic  Tubal  Nephritis,  Chronic 

Bright's  Disease. 

Etiology. — The  frequency  of  the  disease  is  greatest  in  young  adult 
males.  In  children  it  usually  develops  from  the  acute  nephritis  of  scar- 
latinal origin.  The  disease  may  follow  the  acute  form  induced  by 
cold,  pregnancy,  or  other  influences.  Among  infections,  malaria  and 
septicemia  are  important.  In  many  cases  the  excessive  drinking  of 
beer  and  stronger  alcoholic  beverages  induces  the  disease;  syphilis  and 
tuberculosis  sometimes  appear  in  its  etiology.  It  may  follow  chronic 
suppuration,  but  amyloid  degeneration  is  more  common  in  this  rela- 
tion. In  a  great  many  cases,  if  not  in  a  majority,  the  disease  begins 
insidiously  without  definite  recognizable  cause. 

Morbid  Anatomy. — Between  the  large  white  kidney  and  the  small  white 
kidney,  which  may  be  taken  as  the  two  principal  types,  there  are  many 
varieties.  The  former  is  more  common.  In  it  the  organ  is  much  en- 
larged, the  capsule  is  thin  and  nonadherent.  The  surface  is  pale,  ex- 
cept for  the  distention  of  the  stellate  veins.  The  cortex  is  much  thick- 
ened and  pale,  with  occasional  opaque  areas.  Histologically  the  changes 
consist  for  the  most  part  in  fatty  degeneration  of  the  epithelium  and 
glomeruli.  The  glomeruli  are  large  and  the  capillaries  show  hyalin  de- 
generation, the  epithelium  cloudy  swelling  or  hyalin  degeneration.  The 
convoluted  tubules  are  filled  with  casts  largely  made  up  of  desquamated 
fatty  epithelium.  The  interstitial  tissue  is  not  apparently  altered.  In 
the  extreme  large  white  kidney  there  is  a  great  excess  of  fat  above 
that  which  is  usually  seen  in  kidneys  that  are  of  moderate  size,  and  the 
condition  has  been  regarded  as  a  fatty  degeneration  of  the  kidney. 

As  has  been  already  stated,  the  disease  is  always  diffuse,  and  the 
small  white  kidney  represents  the  extreme  degree  of  interstitial  prolifera- 
tion that  is  seen  in  a  strictly  parenchymatous  form  of  the  disease.  In 
size  it  is  usually  about  normal  or  slightly  larger,  rarely  smaller.     The 


568  PRACTICE  OF  MEDICINE 

connective  tissue  is  increased,  the  capsule  thickened  and  moderately 
adherent.  The  capsules  of  the  glomeruli  and  the  intertubular  tissue  are 
increased.  The  smaller  size  of  the  kidney  is  due  to  the  contraction  of 
this  new  tissue.  It  is  often  a  later  stage  of  the  condition  represented 
by  the  large  white  kidney,  but  it  may  develop  independently.  The 
changes  in  the  parenchyma  of  the  two  forms  are  the  same. 

Sometimes  the  cut  surface  appears  mottled,  owing  to  different  stages 
of  degeneration  in  different  parts.  A  hemorrhagic  nephritis  is  also 
recognized,  in  which  small  hemorrhages  have  occurred  into  the  tubules 
of  the  cortex  and  between  them.  The  changes  in  other  organs  are  of 
minor  importance.  Cardiac  hypertrophy  is  occasionally  present,  but  it 
is  more  commonly  associated  with  the  interstitial  nephritis. 

Symptoms. — The  disease  generally  begins  so  insidiously  that  it  is  for 
a  time  unrecognized.  WTien  it  follows  the  acute  form,  the  patient  may 
appear  to  have  improved,  but  the  anemia  persists  and  the  urine  is  still 
dark,  deficient  in  quantity,  and  albuminous.  WTien  it  develops  inde- 
pendently, the  anemia  is  often  the  earliest  symptom,  and  this  may  be 
disregarded  until  pufiiness  of  the  eyelids  or  of  the  ankles  or  hands  at- 
tracts attention  to  it.  Even  when  the  blood-count  does  not  show 
marked  anemia,  the  pallor  is  often  extreme  and  the  face  assumes  a 
peculiar  yellow  hue  in  many  cases.  Before  the  edema  has  become  per- 
sistent the  patient  usually  suffers  from  dyspnea.  As  the  disease  pro- 
gresses, the  dropsy  increases.  It  is  always  more  marked  in  the  morn- 
ing; the  eyelids,  extremities,  and  dependent  portions  of  the  body  are 
most  affected.  Later,  a  tendency  to  the  involvement  of  the  serous  mem- 
branes becomes  manifest,  and  ascites,  hydrothorax,  or  hydropericardium 
may  develop.  Acute  exacerbations  sometimes  occur  in  which  all  the 
symptoms  of  acute  nephritis  are  present.  The  heart  becomes  hypertro- 
phied  chiefly  in  cases  in  which  the  small  white  kidney  is  found — cases 
approaching  nearest  to  the  interstitial  form  of  nephritis.  In  these,  the 
arterial  tension  is  high. 

Gastrointestinal  symptoms  are  frequent  and  often  persistent.  Vomit- 
ing often  becomes  uncontrollable  during  acute  paroxysms  of  the  disease, 
and  a  troublesome  diarrhea  is  common  at  such  times.  The  analysis 
of  the  urine  is  the  key  to  the  diagnosis.  The  quantity  is  reduced,  the 
color  is  high,  the  specific  gravity  is  usually  above  1.025,  and  the  albu- 
min often  exceeds  i  per  cent  by  weight,  the  coagulum  after  boiling  rep- 
resenting a  third  to  a  half  of  the  volume  in  the  test-tube.  After  cen- 
trifugal precipitation,  the  microscope  reveals  numerous  large  and  small 
•hyaHn,  epithelial,  granular,  and  fatty  casts,  epithelium  from  the  tubules 
in  a  state  of  fatty  degeneration,  many  leucocytes,  and  often  a  few  red 
corpuscles.  To  a  certain  extent  these  features  vary  with  the  condition 
of  the  kidneys.  As  the  interstitial  tissue  becomes  more  involved  and  the 
size  of  the  kidneys  is  reduced,  the  quantity  of  urine  is  somewhat  in- 
creased, the  specific  gravity  lower,  and  the  percentage  of  albumin  reduced ; 
the  dropsy  may  also  subside  to  some  extent.  It  is  not  always  possi- 
ble, however,  to  diagnosticate  the  condition  of  the  kidney  by  these 
signs.  The  other  symptoms  are  the  same  in  character  as  those  of  acute 
nephritis.  Drowsiness  and  headache  are  often  prominent  features;  de- 
lirium, restlessness,  and  convulsive  manifestations,  tremors  and  muscular 
cramps  are  more  commonly  met  with  in  the  interstitial  form. 


CHRONIC  NEPHRITIS  569 

Prognosis. — The  prognosis  is  always  unfavorable.  The  possibility 
of  recovery  rapidly  vanishes.  It  is  only  rarely  in  children,  as  a  rule, 
that  the  disease  subsides  after  a  year's  duration.  Death  may  be  the  re- 
sult of  uremia,  edema  of  the  lungs  or  inflammation  of  the  serous  mem- 
branes. 

Treatment. — The  treatment  of  special  symptoms  is  based  upon  that 
of  the  same  conditions  in  acute  nephritis.  The  nearer  a  milk  diet  is 
maintained,  the  less  will  be  the  work  thrown  upon  the  kidneys.  Nitrog- 
enous food  should  be  eaten  sparingly,  a  small  portion  of  meat  being 
allowed  at  only  one  meal  each  day.  Water  should  be  drunk  freely  and 
the  saline  diuretics,  especially  potassium  bitartrate  and  acetate,  may  be 
employed.  Digitalis  is  the  best  diuretic  in  many  cases,  and  the  sodium- 
theobromin  salicylate  administered  with  it  adds  greatly  to  its  action. 
Iron  is  indicated  for  the  anemia ;  its  administration  should  be  regulated 
by  the  condition  of  the  blood  rather  than  by  the  appearance  of  the 
patient.  When  properly  administered,  a  marked  improvement  is  often 
observed,  yet  the  effect  is  rarely  permanent. 

The  patient  must  lead  a  quiet,  temperate  hfe,  free  from  excitement  or 
excesses  of  any  kind.  If  his  circumstances  permit,  he  should  reside  in  a 
moderate,  uniform  climate,  hke  that  of  the  extreme  southern  district 
of  California. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

Sclerosis    of    the   Kidneys,    Granular    Kidney,    Contracted   Kidney,  Gouty 
Kidney,  Renal  Cirrhosis. 

Etiology. — (a)  In  some  instances  the  sclerotic  kidney  is  a  late  result 
of  chronic  diffuse  nephritis  characterized  in  its  early  history  by  promi- 
nent symptoms  on  the  part  of  the  parenchyma;  the  parenchymatous 
nephritis  passes  over  into  the  interstitial  form.  ((^)  In  another  group 
of  cases  it  is  a  primary  affection,  and  in  a  third  (r)  it  is  a  manifesta- 
tion of  an  arteriosclerosis. 

a.  In  the  first  group  it  is  a  further  development  of  the  sclerotic  proc- 
ess seen  in  the  small  white  kidney,  a  further  hyperplasia  of  the  con- 
nective tissue  and  consequent  induration. 

b.  The  primary  form  cannot  always  be  accounted  for.  It  is  more 
frequently  observed  in  men  past  middle  life,  and  more  commonly  in  per- 
sons of  a  gouty  tendency,  and  those  who  have  been  indulgent  of  their 
appetites.  It  is  induced  probably  more  commonly  as  a  result  of  over- 
eating than  as  a  result  of  excessive  drink.  The  excessive  eating  of  meat 
is  regarded  as  especially  influential.  Lack  of  exercise  and  sluggishness 
of  the  bowels,  with  consequent  increase  of  effete  matter  to  be  eliminated 
by  the  kidneys,  is  an  exceedingly  important  element  in  the  production 
of  a  large  proportion  of  cases.  Activity  of  the  mind  as  well  as  activity 
of  the  body  has  been  regarded  as  operative  in  some  cases,  but  like 
alcoholism  these  influences  are  not  usually  alone  in  their  action.  Syphilis 
appears  in  the  history  of  many  cases.  Some  authors  regard  the  in- 
creased work  thrown  upon  the  liver  by  over-eating  and-  drinking  as  the 
more  remote  cause,  through  the  production  of  substances  which  pro- 
duce irritation  of  the  kidneys  in  passing  through  them.  Gout,  chronic 
lead-poisoning,  and  chronic  rheumatism  are  looked  upon  as  causes  in 
some  cases. 


570  PRACTICE  OF  MEDICINE 

c.  In  the  arteriosclerotic  form  the  exciting  cause  does  not  dififer  ma- 
terially from  that  in  the  independent  form,  but  the  result  is  often  much 
less  pronounced  in  the  kidneys,  a  thickening  and  hardening  of  the 
smaller  arteries  of  the  entire  body  often  taking  place. 

Morbid  Anaiomy. — Sclerotic  kidneys  are  small,  each  weighing  less  than 
an  ounce  in  extreme  cases.  The  surface  is  rough  and  granular,  the  color 
dark  red,  rarely  pale,  the  capsule  is  thickened  and  adherent  so  that  it 
cannot  be  stripped  off  without  laceration  of  the  kidney  substance.  Many 
cysts  of  various  sizes  are  often  found  immediately  under  the  capsule. 
The  tissue  is  firm,  and  the  knife  meets  with  much  resistance  in  making 
a  section.  The  cortex  is  more  markedly  atrophic  than  the  pyramidal 
portion.  The  essential  histological  change  is  hyperplasia  of  the  connec- 
tive tissue.  This  affects  to  a  variable  degree  all  the  parts  of  the  kidney, 
but  is  more  pronounced  in  the  cortical  portion.  In  the  pyramids  the 
new  connective  tissue  is  more  uniformly  distributed,  though  less  abun- 
dant. Bowman's  capsule  is  often  supplemented  by  a  thick  layer  of  dense 
connective  tissue,  and  a  similar  thickening  of  the  adventitia  of  the  blood- 
vessels is  often  seen.  Degenerative  changes  also  occur  in  the  parenchyma; 
by  some  writers  this  is  regarded  as  the  primary  change,  by  others  as 
secondary  to  the  sclerosis.  Hyalin  degeneration  and  cloudy  swelling 
are  more  or  less  general  in  the  tufts  and  in  the  capillary  walls,  as  well 
as  between  the  loops.  As  a  result  of  these  changes,  and  to  a  great  ex- 
tent probably  as  a  result  of  pressure,  the  glomeruli  are  often  extremely 
small,  and  many  may  be  entirely  destroyed.  An  occasional  tuft  in  a 
comparatively  normal  condition  is  seen,  however.  The  epithelium  of 
the  renal  tubules  shows  more  or  less  general  cloudiness  or  a  well-marked 
fatty  or  hyalin  degeneration.  Many  of  the  tubules  are  filled  with  masses 
of  granular  detritus  often  in  the  form  of  epithelial  and  other  casts.  Dila- 
tation amounting  to  the  formation  of  cysts  is  not  uncommon.  Pig- 
mentation of  the  interstitial  tissue  is  sometimes  met  with  as  a  result 
of  hemorrhages. 

The  heart  generally  shows  hypertrophy,  especially  in  the  left  ven- 
tricle. This  may  be  secondary  to  the  renal  condition  alone  or  to  the 
general  arteriosclerosis. 

Symptoms. — Not  only  the  invasion,  but  the  entire  course  of  the  disease 
may  be  so  obscure  as  to  escape  recognition  until  near  its  close.  In  a 
majority  of  cases  it  is  rather  a  complication  than  the  disease  itself 
that  first  attracts  attention,  and  many  cases  are  first  recognized  at  the 
autopsy.  The  patient  experiences  no  illness  which  he  regards  of  sufficient 
importance  to  require  the  services  of  a  physician.  In  a  considerable 
group  of  cases,  however,  he  becomes  anemic,  is  sleepless  and  restless. 
Headache  and  dyspnea  are  complained  of,  the  digestion  becomes  im- 
paired, the  tongue  coated,  and  the  bowels  irregular.  The  quantity  of 
urine  voided  is  greatly  increased,  and  the  patient  must  generally  arise 
at  night  to  urinate.  The  color  of  the  urine  is  light  and  the  specific 
gravity  is  low,  often  below  i.oio,  or  even  1.005.  A  trace  of  albumin 
is  present,  constantly  or  at  variable  intervals.  The  solid  constituents 
are  greatly  reduced  in  ratio  to  the  quantity,  but  the  total  quantity 
eliminated  in  each  twenty-four  hours  is  often  about  normal  until  com- 
paratively late  in  the  disease.  Hyalin  casts  can  generally  be  found, 
and,  as  the  disease  advances,  granular  and  fatty  casts  become  more 


CHRONIC  NEPHRITIS  571 

abundant.  Toward  the  termination  of  most  cases,  when,  apparently, 
the  remaining  unaffected  glomeruH  become  involved,  the  albumin  in- 
creases in  quantity,  and  the  specific  gravity  becomes  higher.  In  the  kid- 
ney of  the  arteriosclerosis  patient,  however,  the  quantity,  weight,  and 
color  of  the  urine  may  remain  nearly  normal  throughout,  the  quantity  of 
albumin  is  generally  greater,  and  casts  may  be  found  more  numerous. 

The  heart  is  hypertrophied,  the  arterial  tension  is  high,  the  impulse 
is  strong,  and  the  aortic  second  sound  is  accentuated,  often  with  a  me- 
tallic ring.  The  pulse  is  small  and  hard.  The  skin  is  generally  dry; 
perspiration  can  seldom  be  detected;  edema  rarely  develops,  except  as 
a  complication  due  to  cardiac  loss  of  compensation.  Eczema  often  ap- 
pears, and  pruritus  is  common.  Muscular  cramps  or  twitchings  are 
often  observed.  As  the  disease  advances,  various  disturbances  of  the 
nervous  system  are  of  frequent  occurrence,  as  disorders  of  sight  and 
bearing,  and  retinal  hemorrhages.  Diffuse  retinitis  or  diplopia  is  some- 
times the  first  manifestation  of  the  disease.  The  headache  often  assumes 
the  form  of  migraine.  Delirium  may  develop,  and  convulsions  sometimes 
supervene  shortly  before  death ;  meningeal  or  cerebral  hemorrhage  occurs 
in  some  cases.  The  cases  which  merge  into  a  parenchymatous  type 
toward  the  close  are  generally  marked  by  stupor  and  coma.  Edema  of 
the  glottis  may  develop  suddenly  in  advanced  cases.  Many  cases  ter- 
minate in  uremia,  others  with  chronic  bronchitis,  pneumonia,  or  edema 
of  the  lungs. 

Diagnosis. — The  disease  should  always  be  suspected  when  an  individual 
above  forty  presents  a  history  of  headache  and  insomnia,  with  increased 
excretion  of  urine,  and  when  upon  examination  the  pulse  is  found  to 
be  small  and  hard,  the  heart  hypertrophied,  and  the  second  sound  ac- 
centuated, the  urine  of  low  specific  gravity  and  color,  with  a  trace  of 
albumin  and  a  few  casts.  Polyuria  alone  in  one  past  middle  life  is  a 
suspicious  feature,  and  should  always  lead  to  repeated  examinations 
of  the  urine  for  albumin  and  casts.  The  urine  should  be  let  stand  for  an 
hour  or  two  in  a  conical  glass,  then  poured  out,  and  only  the  last  15 
c.c,  which  contain  the  sediment,  placed  in  the  tube  of  the  centrifuge. 
It  is  well  to  examine  specimens  voided  two  hours  after  a  meal  as  well 
as  those  of  the  morning  and  evening. 

Prognosis. — The  prospect  of  prolonged  life  is  better  than  in  the  chronic 
parenchymatous  nephritis,  but  there  is  always  great  danger  of  a  uremic 
seizure  in  a  pronounced  case.  Severe,  persistent  headache  or  vomiting, 
diarrhea,  uremia,  cardiac  dilatation  or  loss  of  compensation,  the  de- 
velopment of  serous  effusions,  and  the  appearance  of  the  urinary  changes 
indicative  of  more  complete  parenchymatous  involvement  are  unfavor- 
able. The  disease  is  incurable,  and  the  possibility  of  spontaneous  re- 
covery is  inconceivable. 

Treatment. — The  treatment  is  purely  palliative.  As  long  as  the  kid- 
neys are  not  unusually  taxed  by  the  elimination  of  toxic  matter,  there 
is  no  indication  for  the  administration  of  diuretics,  diaphoretics,  or  laxa- 
tives; but  a  large  quantity  of  water  should  be  consumed  in  order  to 
compensate  for  the  increased  elimination,  the  skin  should  be  kept  active 
by  frequent  warm  baths  followed  by  friction  with  a  coarse  towel,  and 
the  bowels  should  be  kept  normally  active.  The  patient  should  wear 
flannels  and  dress  warmly.     If  possible,   he  should  reside    in    a    warm 


572  PRACTICE  OF  MEDICINE 

equable  climate,  like  that  of  southern  Cahfornia,  during  the  entire  year, 
or  at  least  during  the  winter.  Moderate  exercise  is  beneficial,  but  fatigue 
of  body  and  mind,  all  worry,  and  excesses  of  every  kind,  especially  in 
eating  and  drinking,  must  be  avoided.  Alcohol  and  tobacco  should  be 
abandoned.  Drugs  are  of  little  value,  except  for  the  relief  of  symptoms 
as  they  arise  or  to  maintain  the  permeability  of  the  kidneys  when  there 
are  indications  of  obstruction.  The  last  indication  is  met  by  the  ad- 
ministration of  pure  water  or  one  of  the  alkaline  mineral  waters. 

A  moderate  increase  of  arterial  tension  is  necessary  to  maintain  the 
circulation  through  the  inelastic  arteries,  and  it  is  only  when  it  becomes 
excessive  that  drugs  are  required  for  its  reduction.  For  a  time  a  proper 
balance  can  be  maintained  by  the  administration  of  saline  laxatives  or 
an  occasional  purgative  dose  of  calomel,  hot  baths,  sweating,  and  re- 
striction of  diet.  WTien,  however,  the  tension  becomes  persistently  too 
high,  and  especially  if  there  be  evidence  of  venous  engorgement,  glonoin 
must  be  administered,  beginning  with  gtt.  j  t.  i.  d.,  and  gradually  in- 
creasing as  it  is  found  necessary.  The  maximum  dose  is  very  different 
in  different  cases,  and  from  lo  to  15  drops  must  often  be  given.  The 
quantity  should  not  be  increased  if  flushing  of  the  face  is  produced.  The 
remedy  should  be  discontinued  for  a  few  days  after  periods  of  two  or 
three  weeks.  Iron  is  indicated  in  most  advanced  cases,  for  the  anemia. 
The  tincture  of  the  chlorid  is  often  the  best  preparation,  and  a  tem- 
porary improvement  usually  follows  its  administration.  WTien  the  heart 
begins  to  fail,  and  especially  when  dilatation  supervenes,  digitalis  must 
be  given  in  moderate  doses.  Strychnin  can  often  be  used,  to  maintain 
the  heart's  action,  with  as  much  advantage  as  digitalis. 

Treatment  of  Uremia.— The  first  indication  is  the  eHmination  of  the 
poisons  from  the  blood.  A  sahne  purge  should,  therefore,  be  immediately 
administered,  and,  while  its  effect  is  waited  for,  the  patient  should  be 
given  a  hot  bath  in  order  to  produce  profuse  sweating.  Unless  the 
heart  be  too  feeble,  the  sweating  may  be  increased  by  the  administra- 
tion of  pilocarpin,  and  the  effect  prolonged  by  covering  heavily  with 
blankets.  WTien  there  is  great  restlessness,  dehrium,  or  urgent  dyspnea, 
morphin  should  be  carefully  given.  The  arterial  tension  must  some- 
times be  reduced  with  glonoin.  Irrigation  of  the  rectum  with  water  at 
a  temperature  of  120°  to  150°  F.,  after  the  method  of  Gran  din,  has 
yielded  good  results.  If  these  methods  fail  and  the  patient  be  robust, 
great  benefit  may  sometimes  be  obtained  from  the  abstraction  of  1 2  to 
1 8  ounces  of  blood  from  the  arm. 

AMYLOID  KIDNEY. 

WAXY  OR  LARDACEOUS  DEGENERATION  OF  THE  KIDNEYS. 

Amyloid  degeneration  of  the  kidneys  develops  as  an_  independent 
affection,  or  in  connection  with  one  of  the  forms  of  chronic  diffuse  ne- 
phritis. 

Etiology.— The  condition  usually  develops  simultaneously  in  the  kid- 
neys, liver,  spleen,  and  other  organs  of  the  body.  It  is  caused  in  most 
cases  by  prolonged  suppuration,  more  particularly  by  that  accompany- 
ing tuberculosis  or  syphilis.  Suppuration  affecting  bone  or  the  pleura 
is  particularly  liable  to  induce  it.     Sometimes  it  develops  in  cachectic 


PYELITIS  573 

states  without  known  suppuration.  It  has  been  referred  to  malaria, 
gout,  lead-poisoning,  leukemia,  and  chronic  endocarditis  in  some  cases. 

Morbid  Anatomy.— Tht  kidneys  are  generally  large,  firm,  and  pale. 
The  cortex  shows  the  greatest  thickening,  and  on  section  has  a  glis- 
tening (lardaceous)  appearance.  The  glomeruli  are  first  affected  and 
become  more  than  normally  distinct.  The  p3'ramids  are  usually  deep 
red  in  color.  The  amyloid  matter  is  beautifully  demonstrated  by  pen- 
ciling the  cut  surface  with  a  dilute  solution  of  tincture  of  iodin,  and  im- 
mediately washing  away  the  excess  with  water.  This  gives  it  a  ma- 
hogany color.  Late  in  the  disease,  the  infiltration  usually  affects  the 
tubules  as  well  as  the  glomeruli.  On  microscopic  examination  the 
changes  of  parenchymatous  or  interstitial  nephritis  are  found  in  all 
advanced  cases. 

Symptoms. — There  are  seldom  any  manifestations  by  which  the  amy- 
loid disease  of  the  kidneys  can  be  recognized  independently  of  the  asso- 
ciated changes  in  other  organs.  The  urine  is  increased  in  quantit}',  of 
low  specific  gravity,  and  colorless.  Albumin  is  usually  found  in  large 
quantity,  sometimes,  however,  only  as  a  trace,  or  it  may  be  absent. 
Globulin  is  generally  present  in  considerable  quantity,  and  the  urates 
are  deficient.  Hyalin  and  fatty  or  granular  casts  are  usually  found. 
The  casts  occasionally  show  the  distinctive  reaction  to  iodin  and  the 
anilin  dyes.  The  patient  becomes  extremely  anemic  and  develops  a  pe- 
culiar cachexia,  and  edema  often  develops  toward  the  close.  Such  symp- 
tom as  increased  arterial  tension  or  uremia  may  develop  as  a  result 
of  the  associated  interstitial  or  parenchymatous  nephritis.  A  colliqua- 
tive diarrhea,  due  to  the  accompanying  amyloid  infiltration  of  the  in- 
testine, frequently  hastens  the  fatal  issue. 

Diagnosis. — The  amyloid  kidney  is  diagnosticated,  as  a  rule,  more  from 
the  history  and  the  recognition  of  the  associated  affections  than  by  its 
own  symptoms.  An  increased  quantity  of  pale  albuminous  urine  of  low 
specific  gravity,  accompanied  with  enlargement  of  the  liver  and  spleen 
in  a  tuberculous  or  syphilitic  patient,  especially  after  suppuration,  is 
an  almost  invariable  indication  of  amyloid  disease  of  the  kidneys. 

Prognosis. — This  is  always  unfavorable.  The  disease  runs  a  very  va- 
riable course,  however,  sometimes  continuing  several  years,  sometimes 
terminating  fatally  within  a  few  months.  Much  depends  upon  the  extent 
to  which  other  organs,  especially  the  intestines,  are  involved. 

Treatment. — Syphilitic  cases  sometimes  run  a  slower  course  under 
treatment,  and  the  removal  of  suppurative  processes,  by  improving  the 
general  condition  of  the  patient,  enables  him  to  longer  combat  the  dis- 
ease ;  but  there  is  no  means  at  our  command  by  which  it  can  be  arrested. 


PYELITIS. 

PYELONEPHRITIS,   PYONEPHROSIS,   SURGICAL  KIDNEY. 

Definition. — An  inflammation  of  the  pelvis  of  the  kidney,  usually  sup- 
purative in  character,  rarely  catarrhal. 

Etiology. — The  catarrhal  form  is  generally  attributed  to  the  toxins 
of  the  infectious  diseases,  chemical  irritants  like  turpentine  and  bal- 
sams,  or  the  passage  of  renal  calculi.     The  suppurative  form  is  caused 


574  PRACTICE  OF  MEDICINE 

by  the  direct  action  of  the  pyogenic  bacteria,  which,  as  a  rule,  reach 
the  kidney  from  the  lower  urinary  passages,  as  when  gonorrhea,  stric- 
ture, prostatic  abscess,  or  other  suppurative  affection  of  the  urethra, 
bladder,  or  contiguous  part  is  present.  This  form  is  usually  designated 
pyelonephritis.  When  the  suppuration  originates  in  the  kidney  as  a  sup- 
purative interstitial  nephritis,  the  infectious  agent  has  reached  the  kid- 
ney through  the  blood  or  lymph  circulation.  This  form  is  commonly 
associated  with  tuberculosis,  pyemia  from  infected  wounds,  malignant 
endocarditis,  or  other  focus  of  suppuration.  It  is  sometimes  due  to  the 
twisting  of  the  ureter  of  a  displaced  kidney  or  the  growth  of  a  neo- 
plasm, hydatids,  or  the  ova  of  parasites,  sometimes  to  the  lodgment 
of  a  calculus,  although  calculus-formation  is  probably  more  frequently 
a  result  of  the  suppuration. 

Morbid  Anatomy. — When  the  suppurative  process  has  continued  long, 
the  pelvis  of  the  kidney  is  much  enlarged,  thickened,  and  indurated. 
The  ureter  is  similarly  altered  for  a  variable  distance  in  most  cases.  Pus 
is  generally  present.  The  inflammation  extends  also  to  the  kidney, 
the  calyces  become  large,  and  in  extreme  cases  the  kidney  structure  is 
destroyed,  leaving  a  large  pus  cavity  (pyonephrosis).  In  tubercular 
cases,  particularly,  the  pus  often  forms  a  large  case  ousmass,  impreg- 
nated with  lime-salts. 

Symptoms. — The  catarrhal  form  may  be  recognizable  only  by  such 
symptoms  as  pain  and  tenderness  over  the  kidneys,  with  an  increased 
flow  of  pale,  turbid  urine,  of  low  specific  gravity.  Vesical  irritation  or 
cystitis  may  be  produced,  and  fever  commonly  develops,  especially  in 
children,  if  it  be  not  previously  present. 

In  the  suppurative  form,  chills,  high  fever,  and  sweating,  with  pain 
and  tenderness,  are  often  early  symptoms.  In  some  cases,  however, 
these  manifestations  do  not  appear  until  later.  When  the  disease  be- 
comes pronounced,  a  distinct  tumor-like  prominence  often  develops  over 
the  affected  kidney,  and  the  tenderness  becomes  extreme.  The  pain  often 
radiates  toward  the  umbilicus  or  downward  toward  the  testicles.  The 
urine  becomes  laden  with  pus,  albumin,  and  desquamated,  degenerated 
epithelium  and  blood-cells.  The  pus  is  subject  to  marked  variation, 
occasionally  appearing  in  enormous  quantity  as  a  result  of  the  rupture 
of  an  inclosed  pocket  or  removal  of  an  obstruction  in  the  ureter.  When 
the  renal  tubules  become  involved,  casts  may  be  discovered,  if  not  de- 
stroyed by  the  bacteria  always  present ;  the  quantity  of  albumin  is  also 
increased.  Fragments  of  disintegrated  kidney-tissue  are  sometimes 
found.  The  quantity  of  urine  voided  is  much  reduced,  but  the  specific 
gravity  remains  low,  often  below  i.oio.  It  may  be  acid  or  alkaline,, 
the  reaction  depending  upon  the  character  of  the  infecting  micro-organ- 
isms. 

The  general  health  of  the  patient  becomes  greatly  impaired.  He  is 
anemic,  and  ultimately  becomes  cachectic.  There  are  exceptions  to  this 
rule,  however,  cases  in  which  the  suppuration  continues  more  or  less 
constantly  for  years,  especially  in  tuberculous  individuals,  without  much 
impairment  of  health.  Some  cases  develop  sepsis,  and  the  patient  passes 
into  a  typhoid  state,  which  may  terminate  fatally.  A  perinephric  ab- 
scess may  be  produced  by  the  rupture  of  an  abscess  in  the  kidney. 

Diagnosis.— It  is  generally  possible  to  determine  which  kidney  is  af- 


HYDRONEPHROSIS  575 

fected,  by  the  location  of  the  pain  and  tenderness.  Catheterization  of 
the  ureter,  when  it  can  be  done,  affords  a  more  positive  means  in  doubt- 
ful cases,  and  cryoscopy,  determining  the  freezing-point  of  the  urine 
from  each  kidney  separately,  offers  the  most  accurate  means  of  deter- 
mining the  organ  affected  and  the  extent  to  which  its  function  is  de- 
stroyed. 

The  differentiation  of  the  tubercular  from  the  nontubercular  pye- 
litis depends  upon  the  discovery  of  the  tubercle  bacillus  in  the  pus. 
Repeated,  careful  examination  is  usually  necessary,  often  supplemented 
with  intraperitoneal  inoculation  of  animals.  The  presence  of  calculi 
can  often  be  recognized  with  the  fluoroscope. 

Perinephric  abscess  is  excluded  by  the  history  of  the  case,  the  presence 
of  a  definite  tumor,  and  the  absence  of  edematous  swelling;  albuminuria 
is  more  constant  in  pyelitis. 

Cystitis  is  attended  with  more  pain  in  the  bladder  and  frequent  mic- 
turition, the  urine  is  less  albuminous,  though  often  of  higher  specific 
gravity,  and  there  is  no  tumor,  pain,  or  tenderness  in  the  lumbar  region. 
The  diagnosis  cannot  be  made  from  the  character  of  the  epithelium, 
since  the  transitional  type  is  found  both  in  the  bladder  and  renal  pelvis. 
When  the  urine  can  be  obtained  directly  from  the  ureters,  the  presence 
of  pus  in  it  definitely  establishes  the  suppuration  at  a  higher  point. 
Acid  pus  almost  positively  indicates  pyelitis. 

Prognosis. — Catarrhal  cases  usually  recover;  suppurative  cases  run  a 
prolonged  and  finally  unfavorable  course. 

Treatment. — Life  can  often  be  greatly  prolonged  by  surgical  measures. 
When  operation  is  not  required,  the  condition  of  the  patient  may  be 
greatly  improved  by  the  administration  of  alkalis,  especially  sodium 
benzoate  or  salicylate  and  the  alkaline  mineral  waters  in  large  quantity. 
The  oil  of  sandalwood  in  capsules  containing  Tll,x  (0.60);  methylene 
blue,  gr.  iij  to  v  (0.18 — 0.30);  and  urotropin,  gr.  v  to  x  (0.30 — 0.60), 
three  times  daily,  are  all  beneficial.  Urotropin  often  controls  the  suppu- 
ration for  a  long  time,  but  permanent  arrest  of  it  cannot  be  secured. 
The  patient  should  avoid  exposure  to  cold  and  wet,  he  should  be  warmly 
clad,  and  he  should  restrict  his  diet  to  food  which  taxes  the  kidneys 
least. 

HYDRONEPHROSIS. 

Definition. — Dilatation  of  the  pelvis  and  calices  of  one  or  both  kidneys, 
with  atrophy  of  the  parenchyma,  due  to  obstruction  and  the  retention 
of  the  urinary  secretion. 

Etiology.— The  condition  is  sometimes  congenital  and  due  to  obstruc- 
tion of  the  ureter  or  urethra,  as  when  an  abnormally  long  ureter  be- 
comes twisted  or  contains  a  valve.  It  is  sometimes  caused  by  the 
pressure  of  a  tumor,  or  by  disease  of  the  prostate  or  urethra,  and  it 
may  result  from  the  displacement  of  a  floating  kidney,  with  tortion  of 
the  ureter. 

Morbid  Anatomy. — Various  degrees  of  dilatation  and  atrophy  are  met 
with,  from  an  enlargement  of  the  pelvis,  with  little  change  in  the  kidney 
proper,  to  the  conversion  of  the  entire  organ  into  a  smooth-walled  cavity 
free  from  suppuration  and  bounded  by  a  thin  layer  of  the  cortex,  which, 


576  PRACTICE  OF  MEDICINE 

upon  microscopic  examination,  may  be  found  almost  normal  in  structure. 
The  condition  is  usually  unilateral,  except  when  the  obstruction  is  sit- 
uated in  the  urethra  or  in  a  single  ureter,  a  condition  observed  in  a  few 
instances.  The  most  extreme  dilatation  occurs  in  cases  of  prolonged 
partial  obstruction,  and  the  kidney  sometimes  resembles  an  enormous 
cyst. 

Symptoms. — Bilateral,  congenital  cases  usually  terminate  fatally  within 
a  week.  Unilateral  cases  sometimes  do  not  produce  symptoms,  unless 
the  obstruction  be  suddenly  developed,  until  the  tumor  has  attained  a 
comparatively  large  size.  Fluctuation  can  often  be  obtained  over  a  very 
large  tumor,  yet  many  cases  pass  unrecognized,  especially  those  aris- 
ing from  the  pressure  of  a  tumor.  Intermittent  cases  have  been  observed. 
in  which  the  tumor  periodically  disappears,  with  the  discharge  of  a 
large  quantity  of  fluid.  This  is  especially  the  case  in  floating  kidney 
and  may  continue  for  many  years. 

Diagnosis. — In  an  infant  the  condition  is  diff'erentiated  with  difficulty 
from  a  congenital  sarcoma.  Aspiration  and  the  withdrawal  of  a  large 
quantity  of  clear  or  cloudy  fluid  of  low  specific  gravity,  containing 
albumin  and  the  salts  of  urine,  indicate  hydronephrosis ;  the  withdrawal 
of  blood  indicates  sarcoma. 

Ovarian  tumor  can  be  differentiated  by  its  greater  mobility,  its  more 
superficial  situation,  and  the  signs  obtained  through  vaginal  examina- 
tion and  aspiration. 

Pyonephrosis  is  differentiated  by  the  purulent  character  of  the  urine, 
greater  pain  and  tenderness,  and  the  more  or  less  constant  elevation  of 
temperature,  with  other  septic  symptoms  in  many  cases. 

Prognosis. — Hydronephrosis  may  exist  in  one  kidney  for  many  years 
without  serious  impairment  of  health.  The  greatest  danger  to  be  antici- 
pated is  rupture  of  the  cyst  into  the  peritoneal  cavity  or  the  develop- 
ment of  suppuration. 

Treatment. — Little  can  be  done,  unless  through  surgical  measures. 
If  the  obstruction  can  be  removed,  further  destruction  of  the  kidney  is 
prevented,  but  an  operation  is  seldom  possible  until  the  destruction  is 
far  advanced. 


NEPHROLITHIASIS. 

STONE  IN  THE  KIDNEY,   RENAL  CALCULUS,   GRAVEL. 

Definition. — The  formation  of  concretions  within  the  kidney.  The  con- 
cretions vary  in  size  from  microscopic  particles  to  stones  the  size  of  a 
bean  and  include  agglutinated  masses  capable  of  filling  a  greater  part 
of  the  renal  pelvis  (coral  calculi).  (See,  also.  Renal  Infarcts,  page  i8.) 
The  principal  varieties  of  stone  are  the  uric-acid,  calcium-oxalate,  and  the 
phosphatic.  The  first  of  these  is  recognized  by  its  smooth  surface,  its 
hardness,  and  red-brown  color.  The  oxalate  stone  is  hard  and  white. 
Both  these  are  occasionally  incrusted  with  urates  or  phosphates,  the 
result  being  a  comparatively  soft  calculus  with  an  exceedingly  hard 
nucleus.  The  calcium-phosphate  stones  are  grayish,  soft  stones  com- 
posed of  calcium  phosphate  and  the  triple  ammonium-magnesium  phos- 
phate.   In  addition  to  these  forms,  concretions  are  rarely  met  with  which 


NEPHROLITHIASIS  577 

are  composed  of  calcium  carbonate,  cystin,  xanthin,  fibrin,  fatty  or 
saponaceous  matter   (urostealith),  or  indigo. 

Etiology. — Calculi  develop  at  all  ages,  even  in  the  intrauterine  life. 
A  family  tendency  is  often  traceable,  especially  in  gouty  subjects.  Men 
are  more  frequently  affected  than  women.  Improper  food,  as  well  as 
overindulgence  in  eating  and  drink,  is  regarded  as  influential.  In  the 
aged  the  calculus-formation  is  usually  referred  to  an  excess  of  uric  acid. 
The  exciting  cause  is  not  definitely  understood.  A  nucleus  is  no  doubt 
essential.  In  some  cases  this  consists  of  bacteria,  the  ova  of  parasites, 
a  blood-clot,  or  tube-casts.  A  highly  acid  urine,  due  to  excess  of  uric 
acid  and  a  low  percentage  of  salts,  is  believed  to  favor  their  develop- 
ment. 

Symptoms. — A  large  coral  calculus  may  exist  in  the  kidney  for  years 
without  producing  disturbances,  and  the  most  intense  suffering  is  often 
induced  by  the  passage  of  a  stone  the  szie  of  a  pea.  The  pain  is  induced 
by  the  passage  of  the  calculus  through  the  ureter,  and  it  becomes  most 
severe  when  the  stone  becomes  lodged.  These  attacks  of  so-called  renal 
colic  often  occur  periodically  for  many  years.  The  stone  remains  indef- 
initely in  the  renal  pelvis  until  dislodged.  This  often  follows  a  blow, 
a  jolt  or  jar.  In  some  cases  the  passage  of  a  single  stone  is  the  only 
manifestation  of  the  disease  that  is  ever  experienced.  The  renal  colic 
is  usually  set  up  immediately  upon  the  entrance  of  the  calculus  into  the 
ureter.  The  pain  is  sharp  and  lancinating ;  beginning  in  the  region  of  the 
kidney  it  radiates  downward  along  the  ureter  to  the  testicle  and  the 
inner  side  of  the  thigh.  The  testicle  is  retracted.  Strangury  is  developed 
and  nausea  and  vomiting  usually  follow,  sometimes  accompanied  with 
chills,  fever,  cold  sweating,  and  great  prostration.  The  pain  may  radiate 
to  the  back  or  chest.  The  attack  lasts  from  an  hour  to  a  day,  and  ceases 
spontaneously  when  the  stone  finally  drops  into  the  bladder.  There  is 
then  a  copious  flow  of  urine  containing  albumin  and  casts  and  some- 
times tinged  with  blood.  A  feeling  of  soreness  remains  for  a  day  or  two. 
The  calculus  frequently  passes  on  through  the  urethra,  occasioning  more 
or  less  pain,  or  it  may  remain  in  the  bladder  and  become  the  nucleus 
of  a  larger  vesical  calculus. 

WTien  the  stone  remains  in  the  kidney,  becoming  too  large  to  enter 
the  ureter,  and  when  there  are  many  calculi  in  the  renal  pelvis,  more 
or  less  characteristic  symptoms  are  produced.  A  dull  aching  pain  and 
weight  are  felt,  or  periodic  attacks  of  more  intense  suffering  occur.  The 
pain  is  not  always  confined  to  the  affected  side,  but  may  be  reflected 
to  the  other  kidney  or  even  be  confined  to  it.  Hematuria  is  not  com- 
mon, but  it  may  occur  in  these  cases.  Pyuria,  with  or  without  other 
symptoms  of  pyelitis,  may  accompany  the  condition.  Reflex  manifesta- 
tions occasionally  develop,  as  gastric  disturbances,  and  headache  ap- 
proaching the  character  of  migraine.  A  renal  intermittent  fever,  similar 
to  the  intermittent  fever  of  gall-stones,  has  been  described  in  cases  asso- 
ciated with  pyuria. 

Diagnosis. — The  pain  sometimes  resembles  that  of  gall-stones,  but 
in  that  condition  there  is  generally  slight  jaundice,  clay-colored  stools, 
inlargement  of  the  gall-bladder,  bile  in  the  urine;  the  pain  radiates  to 
the  umbilicus  or  shoulder,  and  there  is  no  retraction  of  the  testicle. 

Intestifial  colic  is  differentiated  by  the  abdominal  distention,  diarrhea, 

37 


578  PRACTICE  OF  MEDICINE 

borborygmi,  and  the  absence  of  urinary  changes  or  tenderness  in  the 
region  of  the  kidney. 

A  vesical  calculus  may  occasion  pain  in  the  kidneys,  which  is  generally 
bilateral;  tenesmus  is  present,  the  urine  is  alkaline  and  contains  much 
mucus.  The  X-ray  sometimes  affords  the  most  positive  means  of  dif- 
ferentiation. 

Prognosis. — The  prognosis  is  always  grave  and  at  any  time  corre- 
sponds to  the  extent  to  which  the  kidney  is  damaged. 

Treatment. — The  treatment  of  a  large  or  impacted  stone  is  purely 
surgical.  There  is  no  other  means  of  removing  a  stone  once  formed. 
The  further  growth  of  a  uric-acid  stone  may  possibly  be  retarded  by 
keeping  the  urine  alkaline  through  the  administration  of  alkalis,  and 
that  of  the  phosphatic  calculus  by  maintaining  its  acidity  with  benzoic 
acid,  gr.  v  (0.3)  in  capsules  three  times  a  day.  Piperazine  has  not 
proved  satisfactory,  although  it  is  capable  of  dissolving  calculi  outside 
of  the  body.  It  may  be  tried  in  the  daily  quantity  of  gr.  xv  (i.o) 
dissolved  in  a  quart  of  water.  A  large  quantity  of  water  should  always 
be  drunk  by  these  patients,  and  pure  water  is  better  than  that  laden 
with  mineral  salts  to  be  eliminated  through  the  kidneys,  unless  they  are 
required  for  the  regulation  of  the  reaction  of  the  urine.  The  diet  should 
be  regulated  with  a  view  to  maintaining  the  desired  reaction. 

Renal  colic  requires  the  administration  of  morphin  hypodermically, 
and  in  some  cases  the  inhalation  of  a  little  chloroform  must  be  given 
until  the  morphin  takes  effect.  The  complete  relaxation  of  narcosis 
favors  the  passage  of  the  stone.  Hot  fomentations  or  poultices  to  the 
lumbar  region  assist  in  the  relief  of  pain,  and  a  full  hot  bath  is  more 
effective.    Hot  lemonade  or  other  hot  drinks  should  be  given. 


PERINEPHRIC  ABSCESS. 

PERIRENAL  ABSCESS. 

Deffnit/on. — Suppurative  inflammation  of  the  connective  tissue  about 
the  kidney. 

Etiology. — The  disease  is  usually  secondary  to  suppurative  inflamma- 
tion in  or  near  the  kidney  or  to  the  rupture  of  an  abscess  in  the  kidney 
or  appendix,  caries  of  the  vertebrae,  or  empyema.  It  sometimes  results 
from  trauma,  falls,  blows,  or  wounds,  and  it  may  follow  the  acute  in- 
fectious diseases  of  childhood. 

HSorbid  Anatomy. — The  formation  of  a  distinct,  localized  abscess  is 
exceptional.  As  a  rule,  the  pus  surrounds  the  kidney  and  burrows  along 
the  psoas  muscle  toward  the  groin  or  upward  to  the  lung,  sometimes 
penetrating  one  of  the  abdominal  viscera.  The  tissues  about  the  kid- 
ney are  found  in  a  greatly  altered  and  indurated  condition. 

Symptoms. — There  are  usually  great  pain  and  tenderness  over  the  af- 
fected kidney,  with  swelling  and  edema  of  the  overlying  tissues.  The 
pain  is  often  referred  to  the  hip,  or  it  may  radiate  downward  and  the 
testicle  may  be  retracted.  The  patient  lies  with  the  affected  thigh  drawn 
up,  and  in  walking  leans  toward  the  opposite  side,  bending  forward. 
Chills,  fever,  and  other  indications  of  sepsis  generally  develop  unless  the 
pus  is  early  evacuated. 


TUMORS  OF  THE  KIDNEY  579 

Diagnosis. — The  distinctive  points  are  the  diffused  swelling  and  the 
edema  in  the  lumbar  region,  the  absence  of  pyuria  in  most  cases,  and 
the  withdrawal  of  pus  by  aspiration. 

Treatment — The  treatment  consists  in  opening  the  abscess  early  and 
maintaining  thorough  drainage. 

CYSTIC  KIDNEY. 

Several  varieties  of  cysts  occur  in  the  kidney,  (^r)  Congenital  cysts 
are  usually  numerous  in  both  kidneys,  varying  in  size  up  to  an  inch  in 
diameter  and  enlarging  the  kidneys  to  such  an  extent  that  they  may 
together  weigh  five  or  six  pounds.  The  cysts  contain  a  clear  or  cloudy 
fluid,  sometimes  dark  in  color,  in  which  albumin  and  triple  phosphates, 
blood-crystals,  cholesterin,  and  fat-crystals  may  be  found.  Their  cause 
is  not  known.  Death  usually  occurs  before  or  soon  after  birth,  but  an 
apparently  congenital  cystic  condition  has  been  found  in  aged  persons. 
(/;)  Dermoid  cysts  have  been  found  in  the  kidney,  (r)  A  general  cystic 
condition  affecting  the  kidneys,  liver,  and  spleen  has  been  observed, 
((/)  The  retention  cysts  resulting  from  the  dilatation  of  obstructed 
tubules  have  been  referred  to  under  Chronic  Interstitial  Nephritis. 

Symptoms. — Small  cysts  are  usually  associated  with  the  symptoms  of 
chronic  interstitial  nephritis,  sometimes  with  the  addition  of  hematuria. 
Large  cysts  are  generally  recognizable  both  by  their  size  and  by  mani- 
festations on  the  part  of  the  kidneys.  The  largest  may  occupy  the 
greater  part  of  the  abdominal  cavity  without  occasioning  great  disturb- 
ance. Pressure  symptoms  are  not  infrequently  excited.  One  or  more 
firm,  smooth  tumors  may  be  felt  in  the  region  of  the  kidney  or  lower 
and  nearer  the  abdominal  wall.  Fluctuation  can  sometimes  be  elicited. 
Some  cases  pass  unrecognized,  however,  until  uremia  is  suddenly  devel- 
oped, and  some  are  discovered  only  after  death. 

Treatment — Nothing  can,  as  a  rule,  be  accomplished  by  treatment. 
Removal  of  the  affected  kidney  is  rarely  justifiable. 


TUMORS  OF  THE  KIDNEY. 

Both  benign  and  malignant  growths  are  met  with  in  the  kidney.  The 
former  are  uncommon  and  seldom  occasion  much  disturbance.  They 
include  fibromata,  adenomata,  lymphadenomata,  lipomata,  and  angio- 
mata.  Papillomata  are  sometimes  found  in  the  renal  pelvis.  Of  the 
malignant  growths,  sarcoma  is  more  frequent  than  carcinoma.  Either 
may  be  primary  or  secondary.  Rhabdomyomata,  alveolar  sarcomata 
containing  striped  muscle-fibers,  are  occasionally  met  with.  The  en- 
cephaloid  cancer  is  the  most  common  form. 

Symptoms. — A  gradually  enlarging  tumor  is  recognized  in  the  region 
of  the  kidney,  becoming  more  prominent  anteriorly  as  it  enlarges  and 
usually  pushing  the  colon  before  it.  The  growth  is  rapid,  the  tumor 
hard.  Pressure  symptoms  may  supervene  and  the  adjacent  organs  may 
be  invaded  by  the  growth.  Pain  is  variable  and  may  be  absent,  or 
sharp  and  radiating.  Hematuria  is  frequently  developed.  The  patient 
becomes  emaciated  in  most  cases,  and  the  usual  cachexia  develops. 


58o  PRACTICE  OF  MEDICINE 

Diagnosis. — The  malignant  tumors  are  recognized  by  their  rapid 
growth,  the  greater  pain,  and  more  frequent  hematuria.  Fragments  of 
the  tumor  may  rarely  be  found  in  the  urine.  Sarcoma  often  develops 
in  early  childhood,  carcinoma  seldom  before  the  thirtieth  year. 

Enlargement  of  the  retroperitoneal  lymph-glands  in  children  cannot 
always  be  differentiated,  but  the  urinary  changes  are  usually  absent, 
unless  the  ureter  be  compressed.  An  enlarged  spleen  is  distinguished 
by  its  distinct,  notched  margin,  descending  with  inspiration;  the  colon 
generally  lies  behind  it.  Tumors  of  the  liver  are,  as  a  rule,  higher, 
causing  protrusion  of  the  lower  ribs ;  the  lower  margin  of  the  liver  can 
generally  be  recognized  above  the  renal  tumor. 

Tubercular  and  syphilitic  growths  are  recognized  by  their  history  and 
the  presence  of  the  disease  in  other  parts. 

Treatment. — Benign  growths  seldom  require  treatment;  malignant  tu- 
mors can  sometimes  be  successfully  removed. 


SECTION    VIII. 
Constitutional  Diseases. 


ARTHRITIS  DEFORMANS. 

OSTEOARTHRITIS,   CHRONIC  RHEUMATIC  ARTHRITIS,   RHEUMATOID 

ARTHRITIS. 

Definition. — A  chronic,  progressive  disease  of  the  joints,  afifecting  chiefly 
the  articular  cartilages,  bones,  and  synovial  membranes,  and  producing 
loss  of  function  and  great  deformity. 

Efio/ogy.— The  disease  may  occur  at  any  time  of  life,  but  its  frequency 
increases  from  35  to  55,  and  rapidly  declines  after  that  period.  It  is  rare 
in  children. 

Sex. — It  is  much  more  frequent  in  women  than  in  men,  commencing 
in  most  cases  during  or  after  the  menopause  and  somewhat  oftener  in 
those  who  have  been  sterile.  Earlier  in  life  it  sometimes  follows  rapid 
childbearing  or  uterine  disease. 

He?-edity  plays  a  doubtful  part,  but  there  is  often  an  arthritic  diathesis 
in  the  family,  a  predisposition  to  rheumatism,  gout,  or  arthritis  defor- 
mans. The  daughters  of  gouty  fathers  are  supposed  to  be  more  susceptible. 
The  disease  is  not,  however,  related  to     either  rheumatismor  gout. 

Hygienic  Influences. — Exposure  to  cold  and  wet  is  less  active  than  in 
the  production  of  rheumatism,  but  it  may  aggravate  the  condition 
of  the  patient.  Bad  hygienic  surroundings,  insufficient  or  improper  food, 
and  residence  in  damp  quarters  are  important  factors  in  many  cases. 
Mental  and  nervous  depression,  worry  and  care,  anemia,  malnutrition, 
and  the  excessive  use  of  amylaceous  or  saccharine  food  are  recognized 
as  exciting  causes  and  as  capable  of  producing  exacerbations.  A  dis- 
solute life,  sexual  exhaustion,  and  veneral  disease,  especially  gonorrhea, 
are  mentioned  as  causes.  A  tuberculous  taint  has  been  repeatedly  ob- 
served, and  influenza  and  other  acute  infections  prepare  the  patient  for 
the  disease.  Finally,  injury  is  sometimes  thought  to  contribute  to  its 
production.  There  are  two  principal  theories  with  regard  to  the  im- 
mediate cause  of  the  disease. 

I.  Nervous  Origin.— The  disease  is  thought  to  be  of  nervous  origin. 
This  theory  is  supported  ;  (^a)  By  the  S3^mmetrical  distribution  of  the 
joint  lesions;  (f)  by  the  similarity  of  these  lesions  to  those  occurring 
in  locomotor  ataxia,  syringomyelia,  and  other  affections  of  the  spinal 
cord;  {S)  by  the  frequent  occurrence  in  the  course  of  the  disease  of 
nutritive  changes  (dystrophies)  of  the  skin,  nails,  muscles,  and  bones; 
and  (rt')  by  the  evident  importance  of  shock,  worry,  grief,  and  men- 
tal exhaustion  in  the  etiology  of  some  cases.  The  exact  nature  of 
the  nerve-changes  has  not  been  fully  determined.  Ord  attributed  the 
disease  to  lesions  in  the  trophic  centers  of  the  cord  and  to  peripheral 


582  PRACTICE  OF  MEDICINE 

irritation.  They  have  been  attributed  also  to  the  absorption  of  toxic 
substances  from  without  and  to  autointoxication  of  a  form  that  is  es- 
pecially associated  with  dilatation  of  the  stomach  (Bouchard). 

2.  Infectious  Origin.— T\sx%  theory  is  supported :  (ji)  By  the  fact  that 
micro-organisms  have  been  found  in  the  tissues  and  fluid  of  the  joints. 
(Ji)  The  disease  sometimes  begins  with  an  acute  onset,  (r)  It  frequently 
follows  an  acute  infection;  and  (^)  enlargement  of  the  spleen  and  lymph- 
glands  has  been  noted  in  some  cases. 

Morbid  Anaiomy. — The  lesions  are  usually  symmetrical  and  involve 
primarily  the  articular  cartilages,  synovial  membranes,  and  the  bones. 
Later,  changes  occur  in  the  capsular  and  other  ligaments,  in  the  peri- 
osteum and  muscles,  and  to  complete  the  picture  we  must  include  the 
changes  in  the  nervous  system,  especially  neuritis  and  atrophy.  In  the 
articular  cartilages  the  change  begins  in  the  center,  the  part  farthest 
removed  from  the  blood  circulation.  The  cartilage  becomes  fibrillated 
and  softened  and  is  removed  by  friction  and  absorption,  exposing  the 
underlying  bone.  Around  this  a  process  of  new-formation  takes  place, 
as  in  caries,  and  nodular  masses  are  formed  which  ossify  and  constitute 
the  chief  element  in  the  production  of  deformity  and  the  limitation  of 
motion.  A  bony  ring  is  sometimes  formed.  As  a  result  of  either  process 
the  end  of  the  bone  ap.pears  to  be  enlarged.  As  a  result  of  friction  the 
surface  of  the  bone  becomes  hardened  (osteosclerosis)  and  acquires  an 
ivory -like  polish  (eburnation).  A  rarefying  ostitis  occurs  at  the  same 
time  in  the  spongy  portion,  and  the  articular  face  often  becomes  grooved 
and  deformed.    True  bony  ankylosis  occurs  only  in  the  spinal  column. 

The  synovial  membranes  become  highly  vascular,  thickened,  and  their 
fringes  elongated.  Cartilaginous  nodules  are  sometimes  formed  in  them 
which  become  detached  and  lie  loose  in  great  numbers  in  the  joint  cavity. 
The  synovial  fluid  is  at  first  increased,  but  later  the  joint  becomes  "  dry." 
The  bursse  in  the  vicinity  of  the  joints  are  often  distended  with  fluid, 
forming  cysts.  The  muscles  are  atrophied  and  have  a  brownish  color. 
The  ligaments,  periosteum,  and  tendons  often  undergo  thickening. 

Symptoms. — There  are  three  principal  types  of  the  disease,  known  as 
the  multiple  progressive  and  monarticular  forms  and  Heberden's  nodos- 
ities.    Clinically,  these  forms  have  few  features  in  common. 

I.  The  Multiple  Progressive  Type.— This  may  be  subdivided  into  an 
acute  and  a  chronic  form.  The  acute  form  is  rare  after  the  age  of  40. 
The  joints  are  generally  enlarged  from  the  beginning,  but  in  the  most 
acute  cases  the  pain  is  out  of  proportion  to  the  swelling.  The  skin  is 
not  usually  reddened.  The  small  joints,  especially  of  the  fingers  and  toes, 
are  symmetrically  enlarged.  The  disease  does  not  migrate,  but  continues 
in  the  joints  originally  affected,  while  others  become  involved.  The 
patient  appears  anemic,  and  headache,  anorexia,  and  malaise  are  some- 
times complained  of.  There  is  seldom  elevation  of  temperature  above 
102°  F.  (39.0°  C). 

The  chronic  fonn  is  more  frequent.  It  is  of  insidious  onset.  It  often 
begins  in  a  single  joint  of  a  finger  or  toe,  then  passes  to  the  correspond- 
ing articulation  of  the  opposite  side,  and  afterward  to  others,  until  all 
the  joints  of  the  body  have  been  involved.  The  joints  are  swollen,  pain- 
ful, and  tender.  Neuralgic  pains  often  accompany  those  of  the  joints 
and  are  attributed  to  atrophic  degeneration  of  the  nerve-roots. 


ANTHRITIS  DEFORMANS  583 

2.  Monarticular  Type. — The  disease  is  not  always  confined  to  a 
single  joint,  as  the  name  signifies,  A  single,  large  articulation  is 
generally  more  severely  affected  than  any  other.  This  form  is  more 
frequent  in  men  and  after  the  fiftieth  year,  attacking  especially  the  knee, 
shoulder,  elbow,  and  hip.  When  located  in  the  hip,  it  constitutes  the 
disease  known  as  morbus  coxae  senilis.  It  generally  confines  itself  to 
the  joint  first  affected,  but  that  of  the  opposite  side  may  become  to  a 
less  degree  involved.  The  vertebrae  are  often  aff"ected  (spondylitis  de- 
formans), the  entire  column  sometimes  becoming  fixed  and  motionless 
through  bony  ankylosis.  Motion  of  the  affected  joints  often  produces 
creaking  or  grating  sounds.  The  muscles  atrophy.  The  deformity  may 
be  greatly  added  to  by  the  accumulation  of  fluid  in  the  bursae. 

3.  Heberden's  Nodosities. — These  are  small  exostoses,  "little  hard 
knobs',"  seldom  larger  than  peas,  which  form  on  either  side  of  the  dis- 
tal joints  of  the  fingers.  The  characteristic  destruction  of  cartilage  and 
eburnation  occur  in  the  joint  proper.  The  disease  follows  the  inter- 
mittent course  of  the  other  forms,  with  occasional  attacks  of  pain  and 
swelling.  The  nodosities  are  most  frequently  seen  in  women  between 
30  and  40.  They  are  generally  the  only  manifestation  of  the  disease, 
but  they  may  accompany  the  monarticular  form. 

Arthritis  Deformans  in  Children.— The  disease  is  not  frequent  in 
children.  Koplik,  in  1896,  found  only  18  cases  recorded.  Schiiller  holds 
the  very  plausible  theory  that  all  cases  that  have  been  described  as  oc- 
curring in  children  are  examples  of  polyarthritis  chronica  villosa,  a  dis- 
ease recently  described  by  him.  The  pathological  conditions  of  the  joints 
undoubtedly  conform  more  closely  to  that  disease  than  to  arthritis  defor- 
mans, for  the  articular  cartilages  show  no  destructive  changes,  and  the 
clinical  manifestations  are  much  at  variance  from  those  found  in  adults. 

As  generally  described,  the  disease  begins  in  children  with  acute  symp- 
toms; fever,  sometimes  a  chill,  swelling,  stiffness,  and  tenderness  of  the 
joints.  It  is  more  frequent  in  girls.  The  enlargement  is  due  rather  to 
thickening  of  the  soft  parts  than  of  the  bone.  The  children  generally 
lack  physical  development.  Enlargement  of  the  spleen  and  lymph-glands 
has  been  noted  by  Still. 

Appearance  of  the  Joints. — The  deformity  of  the  joints  is  quite  charac- 
teristic. The  fingers  are  turned  toward  the  ulnar  side,  strongly  flexed, 
and  they  generally  overlap  one  another.  The  distal  joints  may  be 
turned  toward  the  radius.  The  joints  are  generally  firmly  locked.  The 
feet  are  strongly  extended,  and  the  joints  are  often  more  rigid  than 
those  of  the  fingers.  The  deformity  of  the  larger  joints  usually  consists 
of  a  widening  of  the  articulation  by  osteophytic  growths.  The  greatest 
prominence  is  on  a  level  with  the  articular  surface,  as  a  rule.  As  a  re- 
sult of  changes  in  the  hip  and  knee,  the  legs  are  drawn  up  in  most 
cases,  rarely  firmly  extended. 

Diagnosis. — The  disease  is  to  be  differentiated  from  subacute  and 
chronic  rheumatism,  gonorrheal  rheumatism,  gout,  progressive  muscular 
atrophy,  Charcot's  disease,  coxa  vara,  and  polyarthritis  chronica  villosa. 

From  rheumatism,  the  distinction  is  often  difficult  in  the  early  stages 
of  the  disease.  Involvement  of  the  smaller  articulations  and  the  station- 
ary character  of  the  disease  should  arouse  suspicion,  even  in  acute  cases, 
and  especially  when  the  patient  is  a  woman  over  45.     Chronic  rheumatism 


584  PRACTICE  OF  MEDICINE 

usually  involves  fewer  joints,   is  more  likely  to  be  unilateral,   and  the 
joints  do  not  creak. 

Gonorrheal  rheu7natism  may  produce  similar  joint  enlargement,  but 
the  osteophytic  formations  are  absent. 

Chronic  gout  is  distinguished  by  its  affecting  only  a  single  joint,  it 
is  more  painful,  tophi  form  about  the  affected  articulation,  and  arterio- 
scleroses are  common.    There  is  an  inherited  tendency. 

Progressive  muscular  atrophy  is  free  from  joint  enlargement. 

Charcofs  disease  is  distinguishable  by  the  presence  of  the  characteristic 
symptoms  of  locomotor  ataxia,  and  the  osteophytic  formation  is  not 
so  great. 

Coxa  Vara. — Maydl  affirms  that  a  differentiation  often  cannot  be  made 
until  the  joint  has  been  cut  down  upon  and  examined,  but  coxa  vara 
occurs  only  in  young  subjects  at  or  near  puberty. 

Polyarthritis  Chronica  Villosa. — This  disease  occurs  most  frequently  in 
women  before  the  menopause,  sometimes  in  children.  The  lesions  are  con- 
fined to  the  synovial  membrane  and  may  continue  for  a  decade  without 
causing  destruction  of  cartilage.  Pain  is  a  prominent  symptom  and  oc- 
curs independently  of  motion. 

Prognosis. — The  disease  is  incurable,  yet  it  is  not  directly  dangerous 
to  life.  Its  progress  usually  becomes  slower  and  less  painful  as  it  ad- 
vances, and  the  patient,  although  bedridden  on  account  of  weakness  and 
deformity,  may  pass  his  later  years  in  comparative  comfort.  But  the 
confinement  to  bed  often  induces  the  development  of  other  affections, 
notably  bronchopneumonia,  which  may  hasten  the  end. 

Treatment. — The  treatment  is  for  the  most  part  hygienic  and  dietetic. 
Whenever  possible,  the  patient  should  reside  in  a  warm,  equable  climate; 
he  should  at  least  live  in  dry,  healthful  quarters.  Unfortunately,  poverty 
often  prevents  such  measures.  Mere  change  of  air  and  scenery  is  often 
beneficial.  Every  precaution  must  be  taken  against  exposure  and  chill- 
ing of  the  body.  The  diet  should  be  liberal,  including  an  abundance  of 
both  nitrogenous  and  carbohydrate  food.  Codliver  oil,  alone  or  with 
malt,  is  beneficial. 

Internal  medication  is  of  no  benefit,  except  in  the  early  stage  or  dur- 
ing acute  exacerbations.  The  sirup  of  the  iodid  of  iron  is  indicated 
for  the  anemia.  The  salicylates  relieve  the  pain  of  an  acute  exacerba- 
tion. Moderate  exercise  should  be  taken,  just  short  of  fatigue.  The 
joints  should  not  be  given  complete  rest  so  long  as  it  can  be  avoided. 

The  hot-air  treatment  has  been  much  employed  of  late,  with  decided 
benefit  in  some  cases.  It  consists  in  placing  the  affected  limb,  well 
wrapped  in  a  cylinder  constructed  for  the  purpose,  and  raising  the  tem- 
perature within  the  cylinder  to  250°  or  300°  F.  (120°  to  150°  C.) for  from 
half  an  hour  to  an  hour,  repeating  the  treatment  twice  or  three  times 
a  week.  The  benefit  is,  no  doubt,  to  be  attributed  to  a  more  or  less 
permanent  dilatation  of  the  blood-vessels  of  the  joint.  Massage  is  of 
benefit  in  restoring  the  nutrition  to  the  muscles.  . 

CHRONIC  RHEUMATISM. 

Definition.— K  chronic  affection  of  the  joints,  of  insidious  development, 
slow  progress,  and  producing  painful  thickening  and  contraction  of  the 


CHRONIC  RHEUMATISM  585 

fibrous  structures  of  the  articulation,  that  result  in  great  impairment  of 
motion  and  more  or  less  deformity. 

Etiology. — The  disease  usually  appears  after  the  fortieth  year,  and  a 
little  more  frequently  in  women.  A  hereditary  predisposition  is  some- 
times apparent.  Poverty,  hard  labor,  exposure  to  cold  and  wet,  and 
traumatism  are  often  important  factors  in  its  production.  It  is  usually 
a  primary  condition,  rarely  following  acute  articular  rheumatism  and 
only  occasionally  the  subacute. 

Morbid  Anaiomy. — The  disease  progresses  so  slowly  that  there  is  at 
no  stage  any  very  active  pathological  process.  The  synovial  membrane 
is  usually  thickened  and  injected.  The  same  condition  is  often  found 
in  the  capsular  and  other  ligaments  and  in  the  tendon  sheaths  about 
the  articulation.  The  muscles  become  atrophied  from  disuse,  and  there 
is  sometimes  a  neuritis  of  the  peripheral  nerves.  The  articular  surfaces 
are  either  unchanged  or  there  is  a  slight  superficial  erosion  of  the  car- 
tilages. The  synovial  fluid  may  be  normal,  diminished,  or  slightly  in- 
creased in  quantity. 

Symptoms. — The  most  prominent  symptoms  are  pain  and  stiffness  of 
the  joints,  more  or  less  constant  in  character.  The  pain  often  becomes 
greater  toward  evening,  and  the  stiffness  persists  in  the  morning  until 
the  joints  have  been  "limbered  up"  by  exercise.  There  may  be  slight 
tenderness  and  moderate  swelling,  seldom  any  redness.  The  motion  of 
the  affected  joints  becomes  more  and  more  restricted  until  the  condi- 
tion becomes  practically  one  of  ankylosis.  Acute  exacerbations  occa- 
sionally develop,  with  slight  elevation  of  temperature.  The  disease 
generally  affects  several  joints,  but  in  some  instances  it  is  confined 
to  one  or  more  of  the  larger  articulations,  as  the  shoulder,  knee,  or 
hip.  It  may  attack  only  the  small  joints,  especially  in  those  who  work 
with  the  fingers.  It  sometimes  passes  from  one  location  to  another,  but 
it  is,  as  a  rule,  stationary,  and  it  is  not  infrequently  unilateral.  Neu- 
ralgic pains  are  often  added  to  those  of  rheumatism.  The  general 
health  may  remain  good,  but  the  patient  usually  acquires  an  anemic 
appearance.  Dyspepsia  and  emaciation  develop,  largely,  no  doubt,  as  a 
result  of  the  general  debihty  and  loss  of  rest.  Cardiac  valvular  lesions 
of  a  sclerotic  nature  are  found  as  a  senile  change,  but  not  as  a  result 
of  the  rheumxatism. 

Diagnosis. — The  slow  progress  of  the  disease  and  the  absence  of  all 
acute  manifestations  serve  to  distinguish  the  affection  from  other  joint 
diseases.  The  prognosis  is  unfavorable  with  regard  to  cure,  but  the 
disease  is  not  fatal.  Treatment  may  afford  comfortable  quiescence  for 
many  years. 

Treatment— The  treatment  should  be  directed  to  the  general  condition 
of  the  patient  and  the  relief  of  suffering.  Improvement  of  digestion  and 
nutrition  is  important.  Internal  medication  is  often  of  little  benefit. 
Potassium  iodic!,  guaiacum,  and  sarsaparilla  are  sometimes  useful.  The 
salicylates  are  useless  except  for  the  relief  of  acute  exacerbations.  Cod- 
liver  oil  and  tonics  should  be  employed  to  improve  the  general  nutrition. 
Residence  in  a  dry,  warm  climate  often  arrests  the  progress  of  the  dis- 
ease. Local  applications  of  ointments  containing  camphor,  menthol,  or 
alkalis,  and  embrocations  or  poultices,  often  afford  relief.  Cold  applica- 
tions are  sometimes  better.     The  hot-air  treatment  has  recently  been 


586  PRACTICE  OF  MEDICINE 

employed  with  great  benefit.  Supplemented  with  massage  and  passive 
motion,  it  has  restored  to  usefulness  many  deformed  and  stiffened 
joints. 

MUSCULAR  RHEUMATISM. 

MYALGIA. 

Definition. — A  painful  affection  of  various  voluntary  muscles  and  of 
the  fasciae  and  periosteum,  to  which  they  are  attached.  Special  names 
are  usually  applied  to  it  when  the  muscles  of  certain  regions  are  involved, 
as  torticollis,  lumbago,  pleurodynia,  cephalodynia,  etc. 

Etiology. — The  disease  attacks  individuals  of  any  age,  but  acute  cases 
are  more  frequent  in  children  and  young  adults.  Men  are  more  com- 
monly affected  on  account  of  greater  exposure.  The  rheumatic  or  gouty 
diathesis  and  a  previous  attack  favor  its  development.  Exposure  to 
cold  or  wet,  especially  when  the  body  is  overheated,  or  exposure  of  a 
part,  as  the  neck,  to  a  cold  draft  often  induces  an  attack.  Strains, 
bruises,  and  overaction  of  a  set  of  muscles  may  induce  it,  or  a  myositis 
presenting  the  same  manifestations. 

Pathology. — The  true  nature  of  the  disease  is  not  known,  since  it 
never  proves  fatal.  Many  authors  regard  it  as  a  neuralgia  of  the  sen- 
sory nerves  in  the  muscles,  and  not  as  an  affection  of  the  muscle  tissue, 
but  there  is  some  evidence  of  its  being  a  myositis  with  involvement  of 
the  fasciae  and  periosteum,  since  these  conditions  have  been  seen  in 
cases  of  acute  articular  rheumatism  in  which  the  muscles  were  simul- 
taneously affected.  In  chronic  cases  there  is  a  round-celled  infiltration 
of  the  muscles,  with  proliferation  of  nuclei  and  hyperplasia  of  the  con- 
nective tissue. 

Symptoms. — Pain  is  the  most  important  feature.  It  may  be  severe 
and  paroxysmal  or  it  may  have  the  character  of  a  constant  aching. 
It  is  often  lessened  by  pressure.  It  may  last  for  only  a  few  days  or  for 
several  weeks,  and  recurrences  are  common;  it  may  become  chronic. 
Fever  is  observed  in  not  more  than  a  third  of  the  cases,  and  it  seldom 
exceeds  102° -F.  (38.8°  C).  The  principal  varieties  of  the  disease 
are  : 

(i)  Lumbago,  affecting  the  muscles  of  the  lumbar  region  and  their 
tendinous  attachments.  It  is  probably  the  most  frequent  form.  It 
often  attacks  the  individual  without  warning,  the  first  indication 
being  an  excruciating  pain  in  the  loins  upon  attempting  to  rise  from 
a  sitting  posture.  When  in  bed  the  patient  often  cannot  change  his 
position. 

(2)  Torticollis,  wry-neck,  or  stiff-neck,  affecting  the  anterolateral 
muscles  of  one  side,  less  frequently  those  of  the  back  of  the  neck.  The 
head  is  held  in  a  characteristic  position  and  cannot  be  rotated. 

(3)  Pleurodynia,  usually  involving  the  intercostal  muscles  of  one 
side,  generally  the  left,  less  frequently  the  pectorals  and  serratus  magnus. 
The  pain  is  rendered  extreme  by  coughing  or  sneezing,  and  ordinary 
respiration  is  painful. 

(4)  Cephalodynia,  affecting  the  muscles  of  the  head.  The  terms  scap- 
ulodynia,  omodynia,  and  dorsodynia  are  occasionally  employed  when  the 


GOUT  587 

shoulder  or  upper  part  of  the  back  is  affected.  The  muscles  of  the  abdo- 
men and  extremities  may  be  involved. 

Diagnosis. — The  condition  is  recognized  by  its  location,  the  increase 
of  pain  upon  motion,  and  the  absence  of  constitutional  disturbance. 
Pleurodynia  may  be  confounded  with  intercostal  neuralgia  or  pleurisy, 
but  is  generally  distinguished  by  the  local  tenderness  and  the  absence 
of  tender  points  along  the  nerve-trunks,  as  well  as  by  the  constant 
character  of  the  pain. 

Treatment. — Rest  and  the  application  of  heat,  or  of  ointments  con- 
taining menthol  and  camphor  or  salicylic  acid,  and  counter-irritation 
are  the  best  methods  of  treatment.  In  extreme  cases,  morphin  hypoder- 
mically  may  be  required,  but  it  should  be  avoided  if  possible.  The 
Paquelin  cautery  may  be  advantageously  applied  with  a  few  quick 
strokes.  In  torticollis,  a  hot  poultice  or  turpentine  stupes  often  afford 
relief.  In  lumbago,  the  application  of  a  hot  iron  over  a  few  thicknesses 
of  flannel,  a  hypodermic  injection  of  distilled  water,  or  the  hot-water 
bottle  often  affords  relief.  Acupuncture,  thrusting  long,  sterilized  needles 
into  the  muscles  of  the  back  and  allowing  them  to  remain  for  five  or 
ten  minutes,  is  highly  recommended,  but  often  fails.  In  pleurodynia, 
strapping  the  chest  is  one  of  the  best  measures.  The  constant  current 
is  sometimes  beneficial  in  all  forms  of  the  disease.  A  Turkish  bath  fre- 
quently cuts  short  an  attack.  In  chronic  cases,  potassium  iodid,  guaia- 
cum,  sulphur,  quinin,  nux  vomica,  and  arsenic  should  be  employed  in 
succession,  if  necessary.  A  gouty  subject  should  restrict  his  diet,  and 
drink  freely  of  alkaline  mineral  waters. 


GOUT. 

PODAGRA. 

Definition. — A  perversion  of  nutrition  producing  recurrent  attacks  of 
arthritis,  deposits  of  sodium  biurate  in  and  about  the  joints,  and  vari- 
ous constitutional  disturbances. 

Etiology. — Neither  the  nature  of  gout  nor  its  cause  has  been  satis- 
factorily determined.  The  disease  is  attributed  to  faulty  metabolism, 
especially  to  a  defective  oxidation  of  proteids,  with  deficient  elimination 
of  waste-products,  particularly  the  urates.  The  blood,  it  is  asserted, 
contains  an  abnormally  large  quantity  of  uric  acid,  probably  in  the  form 
of  a  biurate,  which  is  deposited  as  tophi,  little  chalky  masses,  about  the 
joints,  and  occasionally  in  other  localities.  The  disease  is  generally  de- 
scribed as  belonging  peculiarly  to  England,  a  little  less  exclusively  to 
France,  Germany,  and  Holland,  but  it  is  by  no  means  rare  in  the  United 
States.  It  is  apparently  becoming  more  common;  it  is  at  least  more 
frequently  recognized  than  it  was  a  few  decades  ago.  The  more  im- 
portant of  the  recognized  causes  are  : 

(c?)  Age. — It  is  a  disease  of  advanced  life,  but  primary  attacks  gen- 
erally occur  before  50;  very  rarely  before  20  in  the  presence  of  a  strong 
hereditary  tendency. 

(/;)  ^^.v. — Men  are  much  more  frequently  attacked,  chiefly  on  account 
of  their  addiction  to  habits  which  induce  it;  yet  goutiness  is  not  rare 
in  women. 


588  PRACTICE  OF  MEDICINE 

((f)  Occupation. — ^It  is  rather  a  lack  of  occupation  that  induces  the 
disease.  Idleness  and  neglect  of  exercise  are  largely  operative  in  its 
production. 

(^)  Heredity  is  recognized  as  one  of  the  most  important  factors, 
but  it  is  not  commonly  traceable  in  this  country.  In  England  the 
disease  can  be  traced  to  the  parents  or  grandparents  in  more  than  50 
per  cent  of  the  cases. 

(j)  Alcohol  ig  the  most  important  factor,  especially  the  free  indul- 
gence in  fermented  liquors.  The  disease  is  more  frequently  found,  there- 
fore, to  follow  the  free  use  of  wine  and  malt  liquors,  or  the  heavy  beers 
and  ales  of  England  and  Germany,  than  whisky  or  the  hght  beers  of 
America. 

(/)  Food,  especially  excessive  eating,  \vithout  proper  exercise,  is  next 
in  importance  to  alcohol.  Gouty  dyspepsia  is  common,  but  many  cases 
occur  in  individuals  with  vigorous  digestion.  Rich,  highly  seasoned 
food  is  commonly  referred  to  as  the  cause,  but  gout  frequently  occurs 
among  the  poor,  as  a  result  of  defective  nutrition,  bad  hygiene  and  in- 
temperance ("poor  man's  gout"). 

(^)  Toxic  Agents. — Lead  favors  the  production  of  gout.  The  gouty 
deposits  occur  not  only  as  a  result  of  chronic  lead-poisoning,  but,  as 
Garrod  has  shown,  very  commonly  among  painters  and  workers  in 
lead.  Haig  attributes  an  unfavorable  influence  also  to  opium,  cocain, 
strychnin,  mercury,  iodids,  nitrites,  some  of  the  sulphates,  hypophos- 
phites,  lithia,  acids,  and  several  other  agents.  The  acute  form  of 
the  disease  occurs  a  little  more  frequently  in  the  late  fall  and  early 
spring. 

Pathogenesis.— Oux  knowledge  of  the  origin  of  the  disease  is  purely 
speculative.  The  most  important  theories  are  the  uric-acid  theory  of 
Garrod,  Ebstein's  theory  of  nutritive  disturbance,  and  Cullen's  theory  of 
nervous  influence.  All  are  based  upon  the  assumption  that  the  condi- 
tion is  intimately  related  to  the  presence  of  an  excess  of  uric  acid  in 
the  system. 

(i)  Uric- Acid  Theory.— T\\v~>  attributes  the  disease  to  the  presence 
of  an  excess  of  uric  acid  in  the  blood  and  tissues,  and  its  deposit  in 
the  tissues  to  a  deficient  alkahnity  of  the  blood-plasma  and  other  fluids 
which  normally  hold  it  in  solution.  In  an  acute  paroxysm  this  accumu- 
lation of  uric  acid  is  shown  by  a  gradual  diminution  of  the  quantity 
eliminated  by  the  kidneys  for  several  days  before  and  during  the  attack. 
The  inflammation  is  beheved  to  result  from  a  sudden  deposit  of  urates 
in  crystalline  form  in  the  tissues  of  the  joints.  Some  writers  believe 
that  there  is  increased  formation  of  uric  acid  as  well  as  deficient  elimina- 
tion. Ebstein  concludes  that  the  acid  may  be  formed  in  unusual  places, 
as  in  the  muscles  and  in  the  bone-marrow.  Kolisch  thinks  that  the 
kidneys  normally  form  uric  acid,  and  that  the  disease  develops  only 
when  the  function  of  these  organs  is  impaired.  And,  since  he  has  found 
that  ths  xanthin  bases  are  also  increased  in  gout,  he  attributes  the  func- 
tional impairment  of  the  kidneys  to  their  action.  Garrod,  accepting  the 
theory  of  uric-acid  formation  in  the  kidneys,  holds  that  when  uric  acid 
is  found  in  the  blood  it  is  as  a  result  of  its  absorption  from  the  kid- 
neys. It  has  been  found,  in  support  of  Kolisch's  theory,  that  the  in- 
jection of  xanthin  and  hypoxanthin  into  the  blood  is  followed  by  struc- 


GOUT  589 

tural  changes  in  the  kidneys  similar  to  those  of  interstitial  nephritis, 
certain  nervous  disturbances,  high  arterial  tension,  and  ultimately  arterio- 
sclerosis. Other  recent  investigators  maintain,  however,  that  the  uric 
acid  is  derived  from  the  nucleins,  and  that  it  is  not  an  intermediate 
product  in  the  formation  of  urea  from  the  proteids.  And  from  this 
theory  some  have  inferred  that  the  increased  production  is  due  to  a 
destruction  of  leucocytes.  It  is  unfortunate  for  all  these  theories,  that 
attempts  to  produce  the  disease  by  the  injection  of  uric  acid  into  the 
blood  or  by  preventing  its  elimination  through  the  kidneys  have  been 
unsuccessful.  It  is  well  known  that  uric  acid  alone  is  harmless,  even 
when  in  greater  quantities  than  have  ever  been  found  in  the  blood  of 
gouty  persons.  It  is  probable,  therefore,  that  some  other  influence  is 
also  at  work  in  the  production  of  the  disease. 

(2)  The  Theory  of  Nutritive  Disturbance. — Ebstein  in  advancing  this 
theory  argues  that  there  is  a  nutritive  disturbance  in  the  tissues,  with 
necrosis,  especially  in  the  muscles,  which  leads  to  the  production  of 
uric  acid  in  them  and  favors  its  deposit  in  the  cartilages  and  connective 
tissue.  Von  Noorden  attributes  this  tissue-change  to  the  action  of  a 
special  ferment. 

(3)  Nervous  Theory. — This  theory  supplements  the  uric-acid  theory 
by  attributing  the  faulty  metabolism  of  the  proteids  to  a  failure  of 
the  nervous  system  to  regulate  the  nutritive  processes.  Some  writers 
go  so  far  as  to  assume  a  derangement  of  certain  hypothetical  nerve- 
centers  controlling  the  nutrition  of  the  joints  or  the  action  of  the  liver. 
Some  regard  the  disturbance  as  due  to  a  neurosis,  others  to  a  neuritis. 
The  chief  arguments  advanced  in  favor  of  the  nervous  theory  are :  («■) 
The  hereditary  nature  of  the  disease;  ((5)  the  effect  of  such  psychical 
disturbances  as  anger,  grief,  and  fright  in  provoking  an  acute  attack; 
(r)  the  common  occurrence  of  neuralgia  and  myalgia  in  gouty  per- 
sons; (^)  joint  involvement  which  is  common  to  many  nervous  affec- 
tions ;  and  (i?)  the  frequent  occurrence  of  neurotic  disturbances  in  mem- 
bers of  a  gouty  family. 

Morbid  Anatomy. —  (i)  The  Blood. — The  excess  of  uric  acid  in  the 
blood  is  generally  accepted,  but  it  cannot  always  be  demonstrated. 
Garrod's  test  is  made  by  placing  a  thread  in  serum  obtained  from  a 
small  blister,  after  adding  to  each  dram  of  it  six  drops  of  a  28  per 
cent  solution  of  acetic  acid.  In  from  18  to  48  hours  crystals  of  uric 
acid  may  be  found  upon  the  thread.  But  the  test,  when  successful,  is 
not  peculiar  to  gout.  The  only  other  change  in  the  blood  which  has 
been  demonstrated  is  an  increase  of  the  fibrin  in  acute  cases,  since  the 
perinuclear  basophilic  granules  of  Neusser  are  found  not  to  be  charac- 
teristic.   Oxalic  acid  has  also  been  found  in  the  blood  in  some  cases. 

(2)  The  Joints. — Wntn  death  has  occurred  during  an  acute  attack, 
evidences  of  inflammation  are  found  in  the  joints.  There  is  also  a  deposit 
of  sodium  biurate,  even  at  the  earliest  stage.  After  repeated  attacks 
the  signs  of  inflammation  become  less  prominent  and  the  deposits  more 
abundant  until  masses  of  considerable  size  have  been  formed.  4^11  the 
structures  composing  the  articulation  may  have  been  invaded.  This 
deposit  begins  a  short  distance  beneath  the  free  surface  of  the  articular 
cartilages  and  extends  more  deeply  as  the  disease  progresses.  It  at 
first  forms  a  whitish  opacity,  but  later  incrusts  the  cartilage  and  pro- 


59° 


PRACTICE    OF  MEDICINE 


duces  an  appearance  which  Duckworth  has  compared  to  splashes  of  white- 
paint.  The  synovial  membrane  sometimes  contains  the  white  splotches^ 
but  its  fringes  escape.  The  synovial  fluid  in  the  larger  articulations 
sometimes  becomes  thickened  and  may  contain  tufts  of  crystals.  The 
fibrocartilage  and  ligaments  are  later  involved,  and  there  are  generally 
the  distinct  masses  of  deposit  known  as  tophi  or  chalk-stones.  The 
tissues  covering  these  masses  frequently  become  eroded,  and  the  tophi 
finally  protrude  through  the  skin.  Ulceration  of  the  surrounding  skin 
and  sometimes  necrosis  ensue.  The  articulations  most  frequently  af- 
fected are  the  first  joint  of  the  great  toe,  then  the  ankles,  knees,  and  the 
small  joints  of  the  hands  and  fingers.  The  joints  of  the  upper  extremity 
escape  in  many  cases.  Tophi  are  commonly  found  in  the  cartilage 
of  the  ear,  at  the  margin  of  the  helix,  less  frequently  in  the  cartilages 
of  the  nose,  eyelids,  and  larynx.  Rarely  they  are  met  with  also  in  the 
substance  of  the  muscles,  in  the  sclera,  or  in  the  cerebral  and  spinal 
meninges. 

Lesions  are  more  or  less  regularly  found  in  other  localities,  notably 
in  the  kidneys  and  blood-vessels.  The  renal  changes  correspond  to  those 
of  interstitial  nephritis,  with  the  addition  of  the  so-called  uric-acid 
infarcts  both  within  the  tubules  and  in  the  epithelial  cells  and  inter- 
stitial tissue.  The  deposits  are  found  especially  in  the  region  of  the 
papillae  and  on  the  bases  of  the  pyramids.  In  the  blood-vessels  various 
changes  are  seen,  but  most  frequently  an  arteriosclerosis,  sometimes 
a  hypertrophy  of  the  muscular  coat  or  an  atheromatous  deposit.  Hyper- 
trophy of  the  heart  usually  accompanies  the  change.  Chalky  concre- 
tions in  the  valves  have  been  described. 

Symptoms. — The  clinical  manifestations  are  generally  described  under 
the  three  heads  of  acute  gout,  retrocedent  gout,  chronic  gout,  and  gouti- 
ness or  irregular  gout. 

(i)  Acute  Gout.— Theacute  attack  usually  begins  with  premonitory 
indigestion,  restlessness,  headache,  and  often  melancholia,  with  occasional 
twinges  of  pain  in  the  joints  of  the  hands  or  feet.  The  urine  becomes 
scant,  dark,  and  strongly  acid,  and  shows  a  deposit  of  urates  on  cool- 
ing. It  may  contain  traces  of  albumin  or  sugar  (gouty  diabetes). 
The  uric  and  phosphoric  acid  ingredients  are  generally  diminished  shortly 
before  and  during  the  attack,  but  much  depends  upon  diet.  A  chill 
sometimes  occurs.  As  a  rule,  however,  the  patient  is  awakened  in  the 
early  morning  with  an  intense  pain  in  the  distal  joint  of  the  right  big 
toe,  possibly  in  the  left.  The  pain  increases  during  the  next  two  or  three 
nights;  it  may  subside  to  a  great  extent  during  the  day.  Such  parox- 
ysms last  six  or  eight  days ;  they  may  be  prolonged  by  the  involvement 
of  additional  joints.  It  is  described  as  a  burning,  throbbing,  lancinat- 
ing pain  that  seems  to  wedge  the  bones  apart  or  to  press  them  to- 
gether as  in  a  vise.  At  first  the  veins  about  the  joint  become  distended^ 
then  the  skin  becomes  uniformly  swollen,  red,  and  glazed;  the  slightest 
motion,  a  touch,  or  the  weight  of  the  bedclothing  causes  intense  pain. 
Fever  is  often  present,  reaching  102°  or  103°  F.  (38.9° — 39.5°  C).  The 
inflammation  subsides  gradually ;  suppuration  does  not  occur.  Desqua- 
mation of  the  skin  over  the  affected  joint  is  sometimes  observed.  Re- 
currence is  common;  some  patients  have  three  or  four  attacks  every 
year. 


GOUT  591 

(2)  Retrocedent  Gout.— This  term  has  long  been  appHed  to  such 
phenomena  as  violent  gastralgia,  precordial  distress,  dyspnea,  vomiting, 
and  collapse  when  they  occur  at  a  time  when  the  acute  symptoms  of 
gout  are  subsiding.  They  sometimes  follow  the  application  of  cold  to 
the  affected  joints.  Fatal  pericarditis,  apoplexy,  and  uremic  coma  are 
sometimes  included  in  this  class  of  manifestations. 

(3)  Chronic  Gout.— This  is  the  outcome  of  repeated  acute  attacks. 
Its  distinctive  feature  is  the  formation  of  tophi.  These  are  seen  espe- 
cially at  the  sides  of  the  joints,  then  in  the  ligaments  and  other  struc- 
tures, until  marked  deformity  and  immobility  or  ankylosis  are  produced. 
They  are  seen  first  in  the  hands  and  feet,  later,  perhaps,  in  the  elbows 
and  knees,  the  tendons,  particularly  on  the  dorsum  of  the  hands,  in  the 
bursce,  and  elsewhere.    After  ulceration  of  the  skin  they  become  visible. 

Indigestion  is  a  prominent  symptom  in  most  cases,  with  flatulence, 
acid  eructations,  and  constipation.  Irritability,  moroseness,  and  mental 
depression  are  often  observed,  but  not  in  all  cases.  The  disease  has 
always  been  notable  for  its  prevalence  among  men  of  prominence  and 
scholarly  attainments.  As  Sydenham  expressed  it,  "  More  wise  men 
than  fools  are  victims  of  the  affection."  Many  conditions  described 
under  the  head  of  Goutiness  are  more  or  less  uniformly  present,  and 
uremia,  inflammation  of  the  serous  membranes  or  meninges  not  infre- 
quently develop  as  terminal  affections. 

(4)  Goutiness  or  Irregular  Gout.— These  terms,  as  well  as  gouty  or 
lithemic  diathesis,  are  appHed  to  ill-defined  groups  of  symptoms  which 
occur  in  the  members  of  gouty  famihes.  They  are  often  the  only  manifes- 
tations of  acquired  gout.  Acute  attacks  are  often  absent.  Unfortunately, 
there  is  a  tendency  to  attribute  to  the  diathesis  every  disturbance  which 
occurs  in  an  individual  bearing  the  inherited  taint,  whether  it  aff'ects  the 
joints,  skin,  nervous  system,  or  other  parts.  Prominent  among  these 
aff"ections  are  : 

(^?)  Cictaneous  Ef-uptions. — Urticaria  is  common  in  early  life;  chronic 
eczema  in  later  life.  Burning  and  itching  of  the  feet  at  night  are  regarded 
as  gouty  indications. 

(^li)  Digestive  Disorders. — Flatulence,  hyperacidity,  with  pyrosis  and 
"  bihousness,"  with  coated  tongue,  fetid  breath,  and  constipation,  gingi- 
vitis, tonsilitis,  enlargement  of  the  uvula,  congestion  of  the  liver,  hemor- 
rhoids, headache,  colic,  neuralgia,  and  intestinal  catarrh,  are  encountered 
in  some  instances. 

(r)  Respiratory  Disorders. — There  is  often  a  tendency  to  catarrh,  pro- 
ducing attacks  of  coryza,  pharyngitis,  laryngitis,  or  bronchitis.  Em- 
physema and  asthma  are  common,  and  uric-acid  crystals  have  been 
found  in  the  sputum. 

(^)  Circulatory  System. — Arteriosclerosis  is  a  common  change.  Owing 
to  the  high  blood-tension,  changes  are  produced,  not  only  in  the  vessels, 
but  in  the  heart  and  kidneys.  The  right  ventricle  is  hypertrophied,  but 
later  yields  to  dilatation  and  becomes  feeble  in  action.  Dropsy  then 
ensues.  Aneurism  may  be  developed  or  a  cerebral  vessel  may  rupture, 
and  thrombosis  of  the  coronary  arteries  is  often  a  cause  of  death. 

(/)  U'ri?ia?y  System. — Nephritis  may  develop  early  or  late.  "Showers" 
of  uric  acid  occur,  large  quantities  of  sand  or  gravel  being  passed.  The 
small  quantity  of   sugar  often  found  sometimes  increases  into  a  true 


592  PRACTICE  OF  MEDICINE 

diabetic  condition.  Calcium-oxalate  crystals  are  sometimes  found  in 
the  urine.  Urethritis  is  readily  induced  in  gouty  subjects;  some  writers 
believe  that  it  may  develop  spontaneously  after  an  attack. 

(_/)  Eye  Affectiofis. — Iritis,  glaucoma,  and  gouty  lesions  in  the  retina 
or  its  vessels  and  the  optic  nerve,  keratitis  and  panophthalmitis,  have 
all  been  attributed  to  the  gouty  condition. 

Diagnosis. — Acute  gout  is  recognized  by  its  usually  attacking  the 
smaller  articulations  in  the  first  instance.  The  swelling  does  not  wander, 
but  continues  while  other  joints  become  affected.  There  are  also  less  fever 
and  sweating  than  in  acute  rheumatism.  The  habits  of  the  individual 
and  the  condition  of  his  mucous  membranes  are  of  value.  The  chronic 
form  is  usually  made  obvious  by  the  presence  of  tophi  in  the  region  of 
the  joints  or  in  the  ears,  the  history  of  the  diathesis,  previous  attacks, 
and  other  evidences  of  the  disease. 

Treatment. — Hygienic. — Gouty  persons  and  those  predisposed  to  the 
disease  should  abstain  from  fermented  liquors;  they  should  also  avoid 
overeating,  and  take  regular  outdoor  exercise.  They  should  favor  the 
elimination  of  urea  through  the  skin  by  frequent  bathing.  Robust  in- 
dividuals should  take  a  cold  bath  every  morning,  followed  by  vigorous 
rubbing,  and  an  occasional  Turkish  bath ;  those  in  feeble  health,  a  warm 
bath  before  retiring.  They  should  wear  warm  clothing  and  guard 
against  sudden  changes  of  temperature.  Removal  from  a  humid  atmos- 
phere to  a  higher,  dryer  climate  is  often  beneficial. 

Dietetic. — Some  writers  recommend  an  exclusively  vegetable  diet,  oth- 
ers a  mixed  one ;  some  advise  the  use  of  fruit,  others  forbid  it.  In  the 
acute  stages  the  food  should  be  largely  liquid ;  milk,  buttermilk  or  kou- 
miss, broths,  junket,  and  gruels.  Large  quantities  of  water  should  be 
drunk,  and  pure  water  is  doubtless  better  than  water  containing  lithia 
or  other  solids  which  must  be  eliminated  by  the  kidneys.  Alkaline  wa- 
ters afford  relief  from  the  hyperacidity  of  the  stomach,  and  have  the 
advantage  of  appealing  to  the  fancy  of  the  patient.  Much  benefit  may 
be  derived  from  a  prolonged  visit  to  mineral  springs.  Farinaceous  food 
and  fresh  vegetables  are  generally  allowed,  with  the  exception  of  straw- 
berries, cherries,  and  bananas ;  but  sweets  are  to  be  avoided.  Hot  bread 
and  articles  made  of  Indian  corn  are  not  to  be  eaten.  Table  salt  should 
be  eaten  sparingly.    Fats  are  allowed  by  Ebstein. 

Medicinal. — The  acute  inflammation  of  the  joints  is  greatly  relieved  by 
bathing  them  in  hot  water,  then  applying  an  ointment  containing  men- 
thol, or  chloroform  liniment.  A  mixture  containing  one  part  each  of 
guaiacol  and  oil  of  wintergreen  and  two  parts  of  olive  oil  is  soothing  to 
the  pain.  The  joints  should  be  thickly  wrapped  in  flannel.  The  hot-air 
treatment  affords  at  least  temporary  relief. 

The  internal  treatment  should  be  begun  with  the  administration  of  a 
mercurial  purge;  even  when  diarrhea  is  present,  small  doses  of. calomel 
should  be  given.  The  wine  or  tincture  of  colchicum  should  then  be  ad- 
ministered in  doses  of  i^xv  to  xxx  (1.2 — 1.8),  usually  in  combination 
with  potassium,  sodium,  or  lithium  citrate,  bicarbonate,  or  salicylate,  gr. 
XV  (i.o),  every  four  hours  until  the  pain  has  been  relieved.  The  doses  of 
colchicum  should  then  be  reduced  to  Tl|,x  (0.6).  The  action  of  this 
drug  is  cumulative  and  should,  therefore,  be  watched.  Personal  idiosyn- 
crasy often  prevents  its  use.    If  used  too  freely  it  is  apt  to  produce 


RICKETS  593 

vomiting,  epigastric  pain,  diarrhea,  or  renal  irritation.  Morphin  is 
sometimes  necessary  for  the  rehef  of  suffering,  but  it  should  not  be  given 
until  colchicum  has  failed,  since  its  use  should  be  avoided  in  all  chronic 
diseases.  A  few  doses  of  phenacetin  or  lactophenin  in  the  beginning  will 
often  afford  relief  until  the  colchicum  has  had  time  to  act. 


RICKETS. 

RACHITIS. 

Definition. — A  disease  of  infancy  characterized  by  defective  nutrition, 
with  its  most  pronounced  manifestations  in  the  growing  bones. 

Etiology. — The  disease  is  more  common  in  Europe  than  in  America, 
but  it  is  by  no  means  infrequent  among  the  children  of  the  poor  in  our 
large  cities.  Congenital  cases  have  been  recorded,  but  the  disease  seldom 
becomes  apparent  before  the  second  year,  or  until  the  child  has  begun 
to  crawl  and  stand.  Male  and  female  children  are  equally  affected. 
Tardy  rickets  has  been  described,  developing  as  late  as  the  ninth  to  the 
twelfth  year,  but  it  is  at  least  quite  rare.  Improper  food,  as  the  milk  of 
a  pregnant  mother ;  bad  hygiene,  including  lack  of  light  and  ventilation, 
are  important  factors  in  its  production.  But  it  is  occasionally  met  with 
among  the  children  of  the  wealthy,  especially  in  those  fed  upon  con- 
densed milk  and  other  artificial  foods  deficient  in  animal  fats  and  pro- 
teid.  Defective  assimilation  of  lime-salts  doubtless  plays  a  part  in  its 
production.  The  disease  is  probably  independent  of  syphilis,  but  may  be 
modified  by  it. 

Morbid  Anatomy. — The  lesions  are  found  especially  in  the  bones.  On 
account  of  a  deficient  deposit  of  lime,  sometimes  as  a  result  of  the  ab- 
sorption of  already  formed  bony  tissue,  the  bones  remain  or  become  soft 
and  unnaturally  flexible.  The  changes  are  best  studied  in  the  long  bones. 
The  periosteum,  cartilage,  and  often  the  bone  itself,  in  the  early  stages 
of  the  disease,  are  hyperemic.  This  condition  is  in  itself  regarded  as 
sufficient  to  explain  the  other  changes,  since  it  has  been  shown  by  Kas- 
sowitz,  that  hyperemia  prevents  the  deposit  of  lime-salts  and  at  the 
same  time  disturbs  the  nutrition  of  the  bone  previously  formed.  The 
periosteum  may  strip  off  readily,  but  it  frequently  brings  spiculae  of 
bone  with  it,  and  the  underlying  shaft  is  usually  soft  and  porous.  In- 
stead of  the  two  narrow  parallel  lines  which  normally  represent  the  zone 
of  proliferation  between  the  shaft  and  the  epiphyses,  there  are  two 
rather  thick  bands  with  bulging,  serrated  edges.  There  is  a  superabun- 
dant proliferation  of  cartilage-cells,  and  the  remaining  matrix  often  be- 
comes fibrillar.  Unnatural  areas  of  defective  ossification  are  also  seen. 
In  the  flat  bones  of  the  cranium,  these  centers  are  often  large  and  promi- 
nent, producing  the  condition  known  as  craniotabes.  In  the  atrophied 
parts  the  bone  becomes  so  flexible  that  it  can  be  depressed  with  the 
fingers,  to  which  it  gives  the  sensation  of  bending  parchment  (parchment- 
crackling).  The  liver  and  spleen  are  usually  larger  than  normal,  and  the 
systemic  arteries  and  lymph-glands  are  often  enlarged.  After  recovery 
has  occurred,  the  bones  have  their  normal  firmness,  but  a  part  of  the 
deformity  generally  persists  throughout  life. 

Symptoms. — The  development  of  the  disease  is  generally  insidious,  and 

38 


594 


PRACTICE  OF  MEDICINE 


it  is  too  often  overlooked  until  distinct  deformities  have  taken  place.  The 
rachitic  child  generally  suffers  early  from  indigestion  or  distinct  gastro- 
intestinal catarrh.  It  is  especially  susceptible  to  bronchitis  and  other 
affections  of  the  respiratory  organs.  It  is  usually  pale,  often  emaciated 
and  weak.  It  is  fretful,  peevish,  and  restless  at  night;  it  often  rolls  its 
head  until  the  back  of  it  becomes  denuded  of  hair.  It  sweats  profusely. 
It  has  trouble  with  the  irruption  of  its  teeth,  which  may  be  delayed, 
irregular,  or  slow.  The  child  often  cries  with  pain  when  it  is  lifted  from 
its  bed.  There  is  often  slight  fever,  and  the  enlargement  of  the  spleen 
can  be  recognized  early  in  most  cases. 

The  head  generally  appears  large  and  has  a  comparatively  square 
shape  (caput  quadratum),  owing  to  the  prominence  of  the  thickened 
frontal  and  parietal  eminences.  The  fontanels  remain  open  until  the 
second  or  third  year,  and  their  edges  are  extremely  thin  and  flexible.  The 
lower  jaw  often  appears  angular.  The  jaws  are,  in  fact,  poorly  developed. 
The  skin  is  thin,  and  the  veins  stand  out  like  blue  cords.  A  systolic 
murmur  can  often  be  heard  by  auscultation  over  the  anterior  fontanel 
or  parietal  region,  but  it  is  not  peculiar  to  rickets. 

The  Thorax. — The  changes  in  the  thorax  develop  early  and  are  quite 
characteristic.  Along  either  side  there  is  a  row  of  beadlike  prominences 
(the  rosary  of  rickets),  due  to  the  swelling  at  the  junction  of  the  carti- 
lages and  the  ribs.  The  sides  of  the  chest,  along  the  line  of  attachment 
of  the  diaphragm,  is  often  drawn  in,  and  there  is  an  evident  sinking  of 
the  chest-wall  during  inspiration,  particularly  when  the  child  is  suffering 
from  bronchitis.  In  most  cases  the  upper  portion  of  the  thorax  also 
appears  depressed  laterally,  as  though  by  the  hands  of  the  mother  in 
lifting  the  child.  The  sternum  becomes  prominent,  especially  in  its  lower 
portion,  sometimes  to  the  extreme  degree  known  as  pigeon  or  chicken 
breast.  A  posterior  curvature  of  the  spine  is  often  seen  also,  and  the 
vertebral  processes  are  prominent.  The  clavicles  are  often  deformed,  and 
there  may  be  partial  fractures,  especially  at  the  insertion  of  the  steno- 
mastoid  muscle. 

The  abdomen  is  prominent,  partly  as  a  result  of  the  enlargement  of 
the  liver  and  spleen,  but  chiefly  on  account  of  intestinal  distention. 
Deformity  of  the  pelvis  is  usually  present,  and  later  in  the  life  of  a 
woman  it  may  interfere  with  parturition. 

The  extremities  show  a  distinct  enlargement  of  the  epiphyses  and  the 
lower  limbs;  the  tibiae  especially  often  show  characteristic  curvatures, 
either  anteriorly,  posteriorly,  or  laterally.  The  femur  may  also  become 
bent  in  extreme  cases  of  bow-leg  or  knock-knee,  producing  a  waddhng 
gait.  The  upper  extremities  are  less  commonly  affected,  but  the  humerus 
may  become  bent  as  a  result  of  crawling.  Sharp  bends  (green-stick 
fractures)  are  often  produced  by  injuries.  The  deformities  in  nearly  all 
cases  correspond  to  the  manner  in  which  the  weight  of  the  body  has 
been  supported  (carpopedal  spasms). 

Rachitic  children  are  particularly  liable  to  nervous  disturbances,  espe- 
cially to  laryngismus  stridulus  and  convulsions.  Tetany  sometimes  de- 
velops, especially  in  the  arms  and  hands,  occasionally  also  in  the  lower 
extremities. 

The  disease  almost  invariably  runs  a  chronic  course  unless  treatment 
is  instituted  at  an  early  stage.    Improvement  may  be  recognized  by  the 


DIABETES  595 

gradual  closure  of  the  fontanels,  increase  in  the  length  of  the  bones,  and 
improvement  in  the  strength  of  the  patient.  Many  of  the  deformities, 
especially  those  of  the  thorax  and  pelvis,  usually  persist,  and  dwarfism  is 
a  not  unusual  result.  Acute  rickets  (infantile  scurvy)  is  described  on 
page  308. 

Diagnosis. — Early  recognition  of  the  disease  is  important.  Persistent 
restlessness,  peevishness,  and  tossing  of  the  head,  abdominal  distention, 
irregular  or  delayed  dentition,  should  arouse  suspicion  of  a  rachitic  con- 
dition before  osseous  deformity  becomes  apparent.  The  student  should 
disabuse  his  mind  of  the  idea,  too  often  expressed,  that  the  disease  is  a 
rare  one  or  that  it  is  found  only  among  the  poor.  After  deformities 
have  developed,  the  diagnosis  is  apparent. 

Prognosis. — The  disease  is  not  of  itself  fatal,  but  by  favoring  the 
development  of  respirator}^  disorders  and  lessening  the  power  of  resist- 
ance to  the  acute  infections  it  contributes  largely  to  the  mortality  of 
early  childhood. 

Treatment. — The  treatment  in  many  instances  should  begin  before  the 
birth  of  the  infant.  If  conception  occur  during  lactation,  the  child  should 
be  taken  from  the  breast,  both  for  its  own  sake  and  for  that  of  the  fetus. 
The  general  health  of  the  mother  should  be  looked  after.  If  the  child 
must  be  taken  from  the  breast,  and  a  wet-nurse  cannot  be  obtained,  the 
safest  diet  is  properly  diluted  cow's  milk,  to  which  beef-juice,  egg  albu- 
men, barley-water,  or  oatmeal  gruel  may  be  added  as  its  age  increases. 
The  child  must  be  bathed  daily,  and  the  brine  bath  is  especially  recom- 
mended. It  should  also  be  kept  in  the  open  air  and  sunshine  as  much 
as  possible.  It  should  not  be  allowed  to  attempt  to  walk  so  long  as  the 
bones  are  in  an  abnormal  condition.  Extreme  cases  should  be  kept  in 
bed  and  handled  as  little  as  possible. 

Medicinal  Treattnent. — In  mild  cases,  before  the  disease  has  become  ad- 
vanced, improvement  often  begins  promptly  after  the  addition  of  salt  to 
the  food,  as  much  as  is  consistent  with  palatability.  Lime-water,  cal- 
cium phosphate,  and  other  remedies  supposed  to  furnish  lime  to  the  tis- 
sues have  been  recommended,  but  they  are  probably  not  assimilated. 
Phosphorus  is  the  most  highly  esteemed  remedy.  It  should  be  adminis- 
tered in  the  dose  of  1-120  grain  (0.0005)  three  times  daily,  in  codliver 
oil.  Rubbing  the  skin  with  the  oil  is  thought  to  act  beneficially,  particu- 
larly when  there  is  marked  soreness.  The  sirup  of  the  iodid  of  iron  is 
also  useful  in  many  cases.  Orthopedic  treatment  often  becomes  necessary 
for  the  relief  Qi  the  deformities. 

DIABETES. 

Definition. — A  condition  in  which,  owing  to  an  inability  of  the  system 
to  consume  it,  sugar  accumulates  in  the  blood  and  is  excreted  in  the 
urine. 

Etiology. — The  blood  normally  contains  a  small  quantity  of  sugar, 
but  under  ordinary  circumstances  it  is  not  excreted  in  appreciable  quan- 
tity by  the  kidneys.  There  is  attributed  to  the  blood  also  the  power  of 
destroying  a  considerable  quantity  of  sugar  through,  as  some  writers 
believe,  a  glycolytic  ferment  contained  in  the  leucocytes.  When,  however, 
the  quantity  in  the  blood  exceeds  a  certain  limit— a  condition  known  as 


596  PRACTICE  OF  MEDICINE 

hyperglycemia — the  excess  is  carried  off  in  the  urine.  In  order  to  be  re- 
garded as  diabetes  the  glycosuria  must  be  continuous  for  a  period  of 
several  weeks  or  longer.  This  feature  alone  serves  to  distinguish  diabetes 
from  a  transitory  glycosuria  arising  from  a  great  variety  of  causes. 

The  exact  nature  and  specific  cause  of  diabetes  are  alike  unknown.  It 
seems  probable,  however,  that  recent  investigations  have  approached 
very  near  to  the  revelation  of  them.  It  has  been  long  known  that  a 
transitory  glycosuria  may  result  from  :  (<2)  Profound  narcosis  of  ether, 
alcohol,  opium,  or  other  drugs ;  (^5)  from  coma  of  whatever  origin ;  (r) 
from  poisoning  with  carbon  dioxid,  amyl  nitrite,  mercury,  strychnin; 
(^)  from  hysteria,  neurasthenia,  epilepsy,  the  traumatic  neuroses;  and 
(^)  from  chlorosis,  exophthalmic  goiter,  or  the  acute  infectious  diseases. 
The  administration  of  phloridzin,  a  glucosid  found  in  the  bark  and  roots 
of  apple  and  cherry  trees,  also  produces  marked  glycosuria,  but  probably 
of  a  different  kind,  since  its  action  is  known  to  be  exerted  upon  the  renal 
epithelium.  There  is  a  marked  difference  also  in  the  capacity  of  different 
individuals  to  consume  sugar.  In  some  persons  the  ingestion  of  seven 
ounces  (200.0)  or  less  of  grape-sugar  into  an  empty  stomach  produces 
glycosuria,  a  condition  known  as  an  alimentary  glycosuria. 

Diabetes  proper  may  probably  depend  upon  any  one  of  several  patho- 
logical conditions,  the  most  important  of  which  are  believed  to  be  lo- 
cated in  the  liver,  nervous  system,  or  pancreas;  possibly  the  suprarenal 
bodies  are  implicated  in  some  cases.  The  theory  that  the  disease  may 
arise  from  a  perversion  of  the  glycogenic  function  of  the  liver-cells  is  an 
old  one,  supported  by  the  common  discovery  of  pathological  conditions 
in  the  organ  as  well  as  by  the  fact  that  the  liver  is  the  chief  factory  and 
storehouse  of  sugar.  Some  writers  believe  also  that  the  condition  may 
be  a  result  of  disturbed  metabolism  in  the  tissues  generally,  or  of  trophic 
disturbances.  The  conditions  of  the  nervous  system  most  frequently 
associated  with  the  disease  are  the  results  of  injury,  tumors,  or  the  so- 
called  neuroses.  Conditions  causing  irritation  of  the  floor  of  the  fourth 
ventricle  have  been  longer  and  probably  oftener  recorded  than  others, 
but  they  are  not  essential,  sincetumors  in  other  regions  and  inflamma- 
tion of  the  meninges  may  produce  glycosuria. 

In  the  further  study  of  pathogenesis,  two  facts  stand  out  prominently, 
namely,  (i)  that  there  is  in  the  body-fluids  of  the  diabetic  a  ferment 
which  is  capable  of  inducing  glycosuria,  and  (2)  that  in  50  per  cent  of 
all  cases  lesions  can  be  found  in  the  pancreas.  The  first  of  these  propo- 
sitions has  been  established  by  repeated  experiments  in  wiiich  the  injec- 
tion of  diabetic  urine  into  dogs  produced  glycosuria,  even  after  the 
sugar  had  been  removed  from  it  by  fermentation.  The  same  result  has 
been  obtained  also  by  injection  of  the  contents  of  the  intestine  of  a 
diabetic  person  under  the  skin  of  a  rabbit  or  into  the  intestine  of  a  dog. 

The  Pancreas  and  Adrenals. — Complete  removal  of  the  pancreas,  or  com- 
plete destruction  of  it  through  disease,  is  immediately  followed  by  per- 
manent glycosuria,  with  the  production  also  of  aceton,  ox3^butyric  acid, 
and  other  substances  peculiar  to  diabetes.  It  has  been  found,  however, 
that  if  as  little  as  one-fifth  of  the  gland  remains,  glycosuria  is  not  pro- 
duced, even  though  the  communication  with  the  intestine  be  cut  off. 
Or,  if  a  small  portion  of  the  pancreas  be  previously  transplanted  to 
another  part  of  the  body,  the  remainder  of  the  organ  can  be  removed 


DIABETES 


597 


without  causing  glycosuria.  Recent  investigations  by  several  European 
experimenters,  and  by  Opie  and  Steele  in  this  country,  have  further  shown 
that  in  all  cases  of  pancreatic  diabetes  lesions  can  be  found  in  the  islands 
of  Langerhans,  groups  of  cells  abundantly  supplied  with  blood,  but  not 
in  any  way  connected  with  the  pancreatic  duct.  This  secretion  is  there- 
fore an  internal  one,  and  it  is  entirely  different  from  the  pancreatic 
juice.  These  cells  are  found  in  a  state  of  hyalin  or  granular  degenera- 
tion in  many  cases  of  diabetes.  More  recently  Herter  and  Richards  have 
shown  that,  after  the  injection,  into  the  small  animals,  of  dried  suprarenal 
extract,  glucose  invariably  appears  in  the  urine.  They  found  that  the 
effect  was  especially  pronounced  when  the  adrenalin  was  injected  into  the 
peritoneal  cavity  or  applied  directly  to  the  pancreas.  In  the  latter  in- 
stance, the  solution  produced,  not  the  usual  blanching,  but  intense  hyper- 
emia and  engorgement.  In  this  respect  the  effect  is  similar  to  that  pro- 
duced by  the  application  of  solutions  of  potassium  cyanid  or  other  sub- 
stances capable  of  reducing  the  power  of  oxidation.  After  fatal  doses  of 
adrenalin,  the  cells  composing  the  islands  of  Langerhans  were  found  to 
be  in  a  state  of  granular  degeneration.  Herter  concludes  from  these 
facts  that  it  is  probably  an  interference  with  the  internal  oxidizing 
power  of  the  cells  in  the  islands  of  Langerhans  that  is  responsible  in 
large  part  for  the  production  of  diabetes.  Although  all  the  experiments 
referred  to  have  not  been  confirmed,  they  strongly  indicate  the  proba- 
bility that  the  action  of  adrenalin  upon  the  islands  of  Langerhans  is  at 
least  one  of  the  causes  of  their  degeneration  and  consequently  of  dia- 
betes. Flexner's  experiments  seem  to  confirm  the  suspicion  that  the 
regurgitation  of  acid  fluid  from  the  intestine  into  the  pancreatic  duct 
may  cause  a  destructive  inflammation  of  the  gland. 

There  is  some  evidence  that  the  disease  may  be  communicated,  and 
consequently  its  infectious  nature  has  been  suggested.  In  a  little  more 
than  I  per  cent  of  a  large  number  of  cases  the  disease  was  observed 
in  both  husband  and  wife,  and  it  has  been  affirmed  that  a  systematic 
investigation  would  show  glycosuria  in  6  to  8  per  cent  of  the  apparently 
healthy  marital  partners.  The  discovery  of  the  disease  in  several  mem- 
bers of  the  same  household,  not  related,  has  a  bearing  on  this  question, 
although  it  is  argued  also  that  these  individuals  become  affected  because 
they  are  subjected  to  the  same  diet  and  other  influences,  and  not  to  a 
specific  infection. 

Predisposing  Infiicences. — (i)  The  disease  may  occur  at  any  time  of 
life,  but  it  is  more  frequent  after  30.  A  large  proportion  of  adult  cases 
occur  after  50.  Men  are  a  little  oftener  affected  than  women.  (2) 
Heredity  is  an  important  factor.  The  disease  has  repeatedly  been  ob- 
served in  successive  generations  and  among  brothers  and  sisters.  In 
many  instances,  also,  it  has  been  met  with  in  families  of  nervous  tempera- 
ment. It  is  much  more  frequent  among  the  affluent  than  among  the 
poor.  (3)  The  Hebrews  are  particularly  susceptible,  and  in  some  of  the 
large  cities  the  Irish  rank  next.  (4)  Obesity  favors  its  development 
(lipogenic  diabetes).  Striimpell  calls  attention  to  its  frequency  among 
obese  beer-drinkers.  (5)  The  disease  is  more  common  in  cities  than  in 
the  country,  and  in  Europe  than  in  America.  (6)  It  has  occasionally 
followed  the  infectious  diseases,  as  influenza,  scarlatina,  typhoid  fever, 
cholera,  or  syphilis.    Tuberculosis  is  often  associated  with  it,  but  it  usu- 


598  PRACTICE  OF  MEDICINE 

ally  plays  the  part  of  a  terminal  affection.  Trousseau  believed  that  an 
inherited  tuberculous  tendency  increases  the  susceptibility  to  diabetes. 

The  nervous  influences  which  are  believed  to  lead  to  the  affection  are 
many;  among  them  close  application  to  business,  or  other  nervous 
strain,  shock,  worry,  fright,  and  injury  or  disease  of  the  brain  or  cord. 
Conditions  which  lower  the  blood  pressure  as  well  as  those  which  increase 
the  rapidity  of  the  capillary  circulation,  particularly  vasomotor  paral- 
ysis, have  been  regarded  as  the  cause  of  permanent  glycosuria. 

Morbid  Anatomy. — Aside  from  the  lesions  of  tuberculosis  and  nephritis 
which  are  commonly  found  after  death,  the  pathological  changes  are  few. 
The  body  is  extremely  emaciated;  abnormal  areas  of  pigmentation  are 
occasionally  found  in  the  skin.  The  blood  contains  an  excess  of  glucose, 
the  quantity  often  amounting  to  0.4  or  0.45  per  cent  instead  of  the 
normal  0.15  per  cent.  Numerous  fat-granules  are  usually  seen  in  the 
plasma.  The  polynuclear  leucocytes  are  especially  rich  in  glucose.  The 
heart  is  sometimes  hypertrophied;  endocarditis  is  unusual,  but  arterio- 
sclerosis is  common.  The  lungs  are  tuberculous  in  many  cases;  broncho- 
pneumonia or  chronic  interstitial  pneumonia  is  found  in  others.  The 
liver  is  often  fatty  or  cirrhotic  and  pigmented ;  it  is  sometimes  enlarged, 
notwithstanding  the  sclerosis.  The  stomach  is  frequently  dilated.  The 
kidneys  are  generally  hyperemic  and  often  sclerotic.  The  lesions  found 
in  the  nervous  system  are  not  uniform.  In  many  cases  there  have  been 
tumors  or  cysts,  once  a  cysticercus,  pressing  on  the  floor  of  the  fourth 
ventricle,  but  often  in  other  localities.  Perivascular  changes  and  inflam- 
mations of  the  meninges  have  been  described.  The  important  changes 
found  in  the  pancreas  have  been  referred  to  under  Etiology.  The  condi- 
tions leading  to  the  degeneration  of  the  islands  of  Langerhans  have 
probably  not  all  been  recognized.  The  changes  may  be  inflammatory, 
degenerative,  atrophic,  or  neoplastic. 

Symptoms. — The  invasion  of  the  disease  is  usually  so  insidious  as  to 
render  the  precise  time  of  its  beginning  indefinite.  The  patient  becomes 
languid  and  weak,  and  he  rapidly  loses  flesh.  Headache,  nervous  depres- 
sion, insomnia,  and  neuralgia  are  often  complained  of.  The  appetite 
becomes  voracious  (bulimia)  and  the  thirst  almost  unquenchable.  Dis- 
turbances of  digestion  are  not  uncommon,  as  nausea,  eructations,  and 
constipation,  but  in  many  cases  the  digestion  is  remarkably  good.  The 
mouth  becomes  dry  from  deficiency  of  saliva;  the  tongue  becomes  red  and 
glazed ;  aphthous  stomatitis  often  develops  late  in  the  disease.  In  many 
instances  the  thirst  and  polyuria  are  the  first  symptoms  to  attract  the 
attention  of  the  patient.  Three  to  four  quarts  (liters)  are  voided  in  24 
hours  in  the  beginning,  but  in  severe  cases  it  may  rapidly  increase  to  1 2 
or  15  quarts.  The  skin  is  dry  and  harsh,  and  sweating  seldom  occurs 
except  when  tuberculosis  is  also  present.  The  temperature  may  be  sub- 
normal except  under  the  same  condition.  The  pulse  is  rapid  and  its 
tension  is  high.  The  emaciation  and  loss  of  strength  keep  pace  with  the 
progress  of  the  disease,  but  cases  are  occasionally  met  with  in  which  a 
comparatively  large  quantity  of  urine  rich  in  sugar  is  voided  for  years 
without  loss  of  weight  or  recognizable  impairment  of  health.  In  most 
cases  the  emaciation  corresponds  to  the  quantity  of  urine  that  is  voided. 
As  a  rule,  the  disease  progresses  with  a  rapidity  that  is  inversely  propor- 
tionate to  the  age  of  the  patient.    It  is  particularly  rapid  and  fatal  in 


DIABETES  599 

young  children,  but  it  often  lasts  for  many  years  in  the  aged.  Nearly 
all  young  patients  die  in  a  profound  coma;  but  older  persons  usually 
succumb  to  one  of  the  complications.  To  this  rule,  also,  there  are  excep- 
tions. In  some  of  the  more  rapid  cases,  polyuria  is  not  marked,  but 
there  has  been  an  evident  defect  in  the  assimilation  of  albuminoids  and 
fats  as  revealed  by  examination  of  the  feces  and  urine. 

Special  Symptoms. — (i)  The  Urine.— The  quantity,  as  already  stated, 
varies  from  6  or  8  to  30  or  40  pints  in  24  hours.  It  has  usually  a 
pale  straw  color  and  a  high  specific  gravity,  ranging  from  1.025  ^^ 
1.050  or  even  higher.  It  has  a  sweetish  odor  and  acid  reaction.  The 
quantity  of  sugar  varies  from  i  or  2  to  10  per  cent.  Ten  to  twenty 
ounces  may  be  excreted  in  a  day,  and,  exceptionally,  as  much  as  two 
pounds.  (For  sugar  tests  see  page  731.)  The  diagnosis  should  not  be 
based  upon  a  single  examination  of  the  urine,  but  only  upon  repeated 
analyses  during  a  period  of  several  weeks.  The  urea,  and  more  particu- 
larly the  phosphates,  are  often  greatly  increased.  Glycogen  and  aceton 
are  often  present  and  /3-oxybutyric  acid  may  be  found  after  coma  develops. 
Albumin  is  not  uncommonly  present,  and  finely  emulsified  fats  may  be 
found.  Pneumaturia,  or  gaseous  urine,  sometimes  results  from  fermenta- 
tion within  the  bladder. 

(2)  T/ie  Sh'u.—Owing,  no  doubt,  to  the  presence  of  sugar  in  the  per- 
spiration, the  pus-formers  find  the  skin  a  good  medium  for  their  growth ; 
consequently  wounds  rarely  heal  without  suppuration,  furunculosis  is 
common,  and  carbuncles  are  liable  to  develop;  gangrene  and  sloughs 
readily  form.  Eczema  is  often  observed,  and  it  is  particularly  significant 
of  the  disease  when  it  involves  the  genitalia. 

(3)  Respiratory  System. — Acute  tuberculosis,  gangrene  of  the  lung, 
lobar  and  bronchopneumonia  are  frequently  terminal  complications. 
Fat-emboli  have  been  found  in  a  few  instances.  The  breath  has  often 
the  sweetish  odor  of  aceton,  not  unlike  that  of  chloroform. 

(4)  Ciradatoiy  System. — The  chief  affection  is  arteriosclerosis,  which 
may  be  manifested  in  many  ways,  often  in  the  form  of  an  interstitial 
nephritis,  sometimes  as  a  myocarditis,  or  by  the  production  of  cerebral 
hemorrhage,  edema  and,  later  in  some  cases,  gangrene  of  the  extrem- 
ities. 

(5)  Nervous  System. — Coma  is  especially  frequent  in  young  patients. 
Occasionally  it  is  the  first  symptom  to  arouse  suspicion  of  the  disease. 
In  other  cases  it  is  preceded  by  indigestion,  nausea,  vomiting,  or  one  of 
the  respiratory  lesions  accompanied  with  great  dyspnea;  or  it  may 
develop  suddenly  and  with  little  or  no  premonition.  It  may  last  four 
or  five  days,  or  it  may  terminate  fatally  within  a  few  hours.  It  is  at- 
tributed to  the  presence  of  some  toxic  substance  in  the  blood,  possibly 
/J-oxybutyric  acid.  Neuritis  is  comparatively  common,  appearing  as  a 
sciatic,  trigeminal,  intercostal,  or  other  form  of  neuralgia,  as  muscular 
pain  or  cramp,  facial  paralysis,  hemiplegia,  hyperesthesia,  or  paresthesia 
of  small  areas,  the  latter  being  occasionally  the  seat  of  pain.  Herpes 
zoster  sometimes  occurs.  The  knee-jerk  is  occasionally  lost  late  in  the 
disease,  and  there  may  be  steppage  gait,  but  the  posterior  columns  of 
the  cord  are  rarely  or  never  affected  unless  locomotor  ataxia  develop  in 
the  patient.  Atrophy  of  the  optic  nerve  has  been  observed.  Perforating 
ulcer  of  the  foot  is  occasionally  encountered.     Lesions  of  the    central 


6oo  PRACTICE  OF  MEDICIXE 

nervous  system  are  less  frequent,  although  severe  headache  is  not  un- 
usual, and  the  patient  often  becomes  morose  or  hypochondriacal,  and 
general  paralysis  may  occur.  The  sexual  power  is  often  lost;  conception 
rarely  occurs,  and  abortion  is  apt  to  follow. 

(6)  Organs  of  Special  Sense. — Cataract  is  not  uncommon,  and  it  is 
especially  rapid  in  its  development  among  young  persons.  Retinitis, 
atrophy  of  the  optic  nerve,  paralysis  of  accommodation,  or  sudden  amau- 
rosis is  liable  to  occur. 

Diagnosis. — Diabetes  is  to  be  distinguished  from  transient  glycosuria 
and  simple  polyuria;  and  the  diabetic  coma  is  to  be  differentiated  from 
that  of  uremia  and  alcohol.  The  distinction  from  transient  glycosuria  is 
practically  one  of  time ;  but  in  most  cases  of  the  latter  condition  there 
is  less  rapid  emaciation,  the  urine  has  a  lower  specific  gravity  and  con- 
tains less  sugar. 

In  polyuf'ia  the  specific  gra\dty  is  usually  below  i.oio,  and  sugar  is 
not  present. 

In  alcoholic  cojna  there  is  usually  other  e\'idence  of  alcohohsm;  the 
patient  can  be  aroused  to  attempt  the  answer  of  questions;  the  condi- 
tion passes  off  in  a  few  hours.  The  urine  has  a  dark  color  and  lower 
specific  gravity,  and  it  contains  no  sugar,  or  at  most  a  mere  trace. 

In  uremic  cojtia,  dropsy  is  generally  present,  the  urine  is  highly  albu- 
minous and  contains  casts,  but  no  sugar;  the  bladder  may  be  almost 
empty. 

Deception  has  been  practiced,  as  recorded  by  Osier,  through  the  intro- 
duction of  cane-sugar  or  glucose  into  the  urine. 

Bremer  and  Williamson  have  each  proposed  a  blood-test,  which  may 
be  of  value  in  the  diagnosis  of  obscure  cases.    (See  p.  718.) 

Prognosis. — Recovery  from  true  diabetes  is  extremely  rare.  Inter- 
mittent glycosuria,  which  is  probably  often  mistaken  for  diabetes,  is,  on 
the  other  hand,  very  amenable  to  treatment.  In  patients  under  middle 
age,  the  prognosis  is  exceedingly  grave,  while  in  older  persons  the  disease 
usually  runs  a  slow  and  milder  course,  more  amenable  to  treatment. 
The  severity  of  a  case  may  be  estimated  from  the  response  to  the  re- 
removal  of  all  carbohydrates  from  the  food,  as  by  putting  the  patient 
upon  a  milk  diet  for  a  few  days.  If  the  elimination  of  sugar  continues 
without  marked  reduction,  the  case  may  be  regarded  as  a  grave  one. 

Treatment. — Dietetic. — Theoretically  the  patient  should  abstain  en- 
tirely from  carbohydrates,  since  the  glycosuria  depends  to  a  great  extent 
upon  the  quantity  of  these  ingredients  in  the  food,  but  practically  this 
is  next  to  impossible  in  most  cases,  and,  if  too  rigidly  insisted  upon,  it 
is  apt  to  destroy  the  appetite,  and  lead  to  an  occasional  refraction  of 
the  rules  with  highly  injurious  consequences.  It  is  probably  better,  as 
Thompson  advises,  to  allow  a  small  portion  of  bread,  from  two  to  four 
ounces  daily,  preferably  toasted,  for  the  craving  for  bread  generally 
proves  stronger  than  for  any  other  article  of  food.  Potatoes  may  occa- 
sionally be  substituted  for  the  bread,  since  they  contain  a  smaller  pro- 
portion of  starch.  In  other  respects  the  carbohydrates  should  be  ex- 
cluded, bearing  in  mind,  however,  the  apothegm  of  Von  Noorden,  "  Under 
all  circumstances,  the  diet  in  diabetes  must  be  so  ordered  that  the 
strength  of  the  patient  may  be  thereby  maintained  and  as  far  as  possi- 
ble increased."    \\Taen  it  is  found  that  the  patient  is  not  holding  his  own 


DIABETES  60 I 

on  a  restricted  diet,  some  change  should  be  made,  and  the  effect  of  any 
particular  diet  should  be  carefully  estimated  through  repeated  analyses 
of  the  urine.  A  number  of  diabetic  flours  are  offered  in  the  market,  but 
few  of  them  are  reliable,  and  some  of  them  are  largely  adulterated  with 
wheat-starch. 

On  account  of  the  ravenous  appetite  of  the  patient  it  is  often  less 
difficult  to  institute  the  diabetic  diet  by  degrees,  causing  a  daily  reduc- 
tion of  the  quantity  of  carbohydrates,  and  at  the  same  time  giving  a 
substitute,  unless  the  urgency  of  the  case  demands  a  prompt  change. 
Sugar  should  be  the  first  article  enjoined,  and  in  its  place  the  patient 
may  use  saccharin  tablets.  There  is  no  better  diet,  perhaps,  than  one 
consisting  largely  of  fats.  The  patient  should  consume  two  ounces  or 
more  of  butter  daily,  and  as  much  cream  as  his  digestion  will  tolerate. 
Other  sources  of  fat  are,  beef,  bacon,  smoked  sausage,  and  ox  tongue, 
cream  cheese,  mackerel,  salmon,  eels,  and  the  free  use  of  mayonnaise  or 
other  dressings  prepared  with  olive  oil.  Bone-marrow  is  tasteful  to 
many  persons.  One  or  more  of  these  articles  should  be  included  in  the 
dietary  of  each  meal.  The  patient  may  eat  also  beef,  veal,  pork,  venison, 
and  the  meat  of  domestic  or  wild  fowl  and  birds,  also  the  heart,  sweet- 
breads, brain,  and  kidneys,  nearly  all  parts,  in  fact,  except  the  liver;  but 
the  meats  must  not  be  breaded.  Oysters,  lobsters,  crabs,  and  shrimps 
may  be  taken.  Among  vegetables,  those  which  grow  above  the  ground 
are  generally  allowable,  as  lettuce,  celery,  cauliflower,  asparagus,  toma- 
toes, onions,  cabbage,  cucumbers,  and  watercress.  Sour  fruits  may  gener- 
ally be  eaten,  especially  sour  oranges,  apples,  lemons,  cherries,  currants, 
pears,  plums,  strawberries,  raspberries.  Among  liquids  the  patient  may 
take  clear  soups,  especially  bouillon,  turtle,  and  oxtail ;  coffee,  tea,  choco- 
late, cocoa,  with  cream,  but  sweetened  with  saccharin ;  whole  milk,  butter- 
milk, plain  and  carbonated  alkaline  mineral  waters. 

The  list  of  articles  to  be  avoided  usually  includes  bread  and  all  farina- 
ceous preparations,  potatoes  and  other  vegetables  that  grow  below  the 
surface,  and  such  beverages  as  beer,  sweet  and  sparkling  wines,  and  all 
that  contain  sirup.    Confections  are  of  course  to  be  avoided. 

Hygieiiic  Treatment. — The  patient  should  guard  against  overwork,  ner- 
vous strain  and  worry,  and  he  should  take  more  than  ordinary  care  to 
avoid  exposure  to  cold.  He  should  take  moderate  exercise  daily.  At 
the  same  time  the  skin  should  be  kept  in  good  condition  by  frequent 
bathing,  either  warm  or  cold,  according  to  the  reaction  after  the  bath. 
A  cold  bath  in  the  morning  is  the  best  if  well  borne;  the  warm  bath  is 
better  at  night. 

Medicmal  Treatment. — Opium  has  long  held  first  place  among  remedies, 
and  fortunately  it  is  usually  well  borne  and  less  liable  to  develop  the 
habit  than  in  a  normal  individual.  It  is  better,  however,  not  to  inform 
the  patient  that  he  is  taking  it.  It  should  be  given  in  the  form  of  pills 
containing  gr.  ss  (0.032),  two  or  three  times  a  day,  or  codein  may  be 
given  in  the  same  dose,  since  it  is  less  constipating.  The  dose  should  be 
gradually  increased  until  8  or  i  o  grains  are  taken  daily,  or  amelioration 
of  the  symptoms  has  been  obtained.  It  should  be  gradually  withdrawn, 
after  the  elimination  of  sugar  has  nearly  or  entirely  ceased.  Good  re- 
sults have  been  obtained  from  the  use  of  the  arsenite  of  bromin  in  doses 
of  Ti^iij  to  V  (0.18 — 0.30),  and  more  recently  from  a  solution  of  the 


6o2  PRACTICE  OF  MEDICINE 

bromid  of  arsenic  and  gold  in  gradually  increasing  doses  from  gtt.  iij 
to  XV.  Many  other  drugs  have  been  employed  with  alleged  benefit,  es- 
pecially the  salicylates,  creosot,  iodoform,  arsenic,  nitroglycerin,  jambul, 
and  lactic  acid.  A  glycerin  extract  of  the  fresh  or  dried  pancreas,  and 
trypsin,  have  been  employed  on  the  erroneous  assumption  that  they 
supplied  the  internal  secretion  that  is  wanting,  but  little  benefit  has  been 
claimed.  Strychnin  is  an  excellent  tonic,  and  ergot  may  be  combined 
with  it  as  a  vasomotor  stimulant  when  needed.  Constipation  should  be 
guarded  against,  since  it  increases  the  liability  to  coma.  Should  the 
digestion  fail,  the  bitter  tonics  and  a  dilute  mineral  acid  should  be  ad- 
ministered. Codliver  oil  may  be  given  to  supply  the  needed  fat.  A  two 
or  three  grain  pill  of  asafetida  (0.15 — 0.20)  has  been  recommended  for 
the  relief  of  the  feeling  of  insatiety  and  epigastric  gnawing.  The  pruritus 
and  eczema  are  treated  by  bathing  the  skin  with  a  boric-acid  or  sodium- 
hyposulphite  solution,  and  applying  an  ichthyol  or  other  ointment. 

The  coma  is  usually  fatal,  and  little  can  be  done  to  delay  the  result. 
Inhalation  of  oxygen  has  been  thought  of  benefit,  and  large  doses  of 
sodium-bicarbonate,  have  been  recommended  to  reduce  the  acid  intoxica- 
tion. Subcutaneous  or  intravenous  injection  of  physiological  salt-solu- 
tion should  be  tried,  since  it  has  proved  beneficial,  to  the  extent  of 
temporarily  restoring  consciousness  in  a  few  instances. 

DIABETES  INSIPIDUS. 

Definition. — A  chronic  condition  in  which  anexcessive  quantity  of  nor- 
mal urine  is  voided  daily  by  a  person  who  in  other  respects  is  in  good 
health. 

Eiiology. — The  cause  is  unknown.  From  analogy  the  disease  is  gener- 
ally regarded  as  of  nervous  origin.  It  sometimes  follows  emotional  ex- 
citement, concussion,  or  other  injury  of  the  brain,  as  well  as  trauma  of 
the  trunk  and  extremities,  or  such  acute  infectious  diseases  as  typhoid 
fever,  malaria,  or  cerebrospinal  meningitis.  Again,  it  has  been  attributed 
to  congenital  syphilis  and  malnutrition.  In  some  instances  the  condi- 
tion has  followed  sunstroke  or  the  drinking  of  a  large  quantity  of  water 
on  a  hot  day.  It  is  to  be  distinguished,  however,  from  the  excessive 
flow  of  urine  which  is  due  to  excessive  drinking  in  polydipsia,  a  condi- 
tion characterized  by  excessive  thirst  and  often  a  hysterical  manifesta- 
tion. 

.,  The  disease  is  a  rare  one.  It  occurs  most  frequently  in  young  boys, 
sometimes  in  girls ;  it  may  develop  in  middle  life,  seldom  later.  It  some- 
times appears  to  be  inherited,  and  congenital  cases  have  been  observed. 

Morbid  Jinafomy. —There  are  no  essential  lesions.  Various  lesions  of 
the  nervous  system  have  been  found.  The  kidneys  are  sometimes  en- 
larged and  congested.  Dilatation  of  the  renal  pelvis  and  ureters  and 
hypertrophy  of  the  bladder  are  sometimes  present.  Death  has  usually 
been  the  result  of  an  independent  affection,  as  tuberculosis. 

Symptoms. — The  condition  develops  gradually  in  the  absence  of  a 
definite  cause,  otherwise  abruptly.  The  essential  symptom  is  the  marked 
increase  in  the  volume  of  urine.  As  much  as  8  or  10  quarts  (liters)  are 
often  excreted  in  24  hours,  and  cases  have  been  observed  in  which  the 
quantity  reached  three  or  four  times  this  limit.    The  specific  gravity 


OBESITY  603 

usually  ranges  from  i.ooi  to  1.004,  and  the  color  is  extremely  pale. 
The  total  solid  constituents  may  remain  normal.  Sometimes  there  is 
slight  excess  of  urea,  and  inosite,  phosphoric  acid,  sulphuric  acid,  creat- 
inin,  and  very  rarely  a  mere  trace  of  albumin  or  sugar  have  been  noted. 
The  thirst  is  extreme,  and  the  dryness  of  the  tongue  and  skin  resembles 
that  of  diabetes  mellitus,  but  furunculosis  is  rare.  Salivation  has  been 
noted.  The  appetite  is  generally  good,  and  the  general  health  may  be 
undisturbed  for  many  years.  In  cases  due  to  a  definite  cause,  however, 
there  may  be  decline  with  emaciation,  languor,  feebleness,  and  sometimes 
insomnia.  Diminution  of  the  urinary  secretion  sometimes  follows  the 
development  of  an  intercurrent  malady.  Recovery  is  extremely  rare,  but 
death  is  usually  a  result  of  another  disease,  as  tuberculosis,  pneumonia, 
or  cancer. 

Diagnosis. — The  condition  is  to  be  distinguished  from  the  polyuria  of 
diabetes  mellitus,  hysteria,  and  interstitial  nephritis.  From  the  first  of 
these  it  is  readily  distinguished  by  the  low  specific  gravity  of  the  urine 
and  the  absence  of  sugar;  from  hysterical  polyuria,  by  its  permanent 
character  and  the  absence  of  hysterical  manifestations;  from  that  of 
interstitial  nephritis,  by  the  absence  of  albumin  and  casts  or  other  evi- 
dence of  ill  health. 

Treatment — It  is  useless  to  restrict  the  diet  or  to  limit  the  quantity 
of  fluid  consumed,  except  so  far  as  the  thirst  can  be  relieved  by  chipped 
ice  instead  of  water.  Opium  has  been  employed,  but  it  is  not  curative. 
Valerian,  in  doses  of  5  grains  (0.30)  of  the  powdered  root,  gradually 
increased  to  20  grains  (1.30),  three  times  a  day,  has  proved  of  benefit. 
Ergot,  the  salicylates,  arsenic,  strychnin,  bromids,  carbolic  acid,  atropin, 
and  galvanization  of  the  cervical  spine  have  all  been  recommended.  If  a 
cause  for  the  condition  can  be  discovered,  it  should  be  treated.  Con- 
genital syphilis  may  thus  call  for  specific  treatment. 

OBESITY. 

Definition. — A  condition  of  disordered  nutrition  characterized  by  a 
greatly  increased  development  of  adipose  tissue. 

Etiology. — The  proximate  cause  is  generally  regarded  as  deficient 
oxidation.  The  condition  may  be  to  a  great  extent  inherited,  but  it  is 
seldom  transmitted  to  all  members  of  a  family.  By  some  writers  it  is 
thought  to  be  related  to  the  uric-acid  diathesis,  diabetes,  and  other 
forms  of  perverted  nutrition.  It  is  more  apt  to  develop  after  middle 
life,  but  it  is  not  infrequent  in  children.  The  principal  causes  that  lead 
to  it  are  excess  of  food  and  drink,  especially  of  starches,  sugar,  and  malt 
liquors,  with  deficient  exercise,  yet  many  fleshy  persons  are  remarkably 
abstemious,  and  some  are  overcome  with  fat  in  the  midst  of  an  active 
life. 

Morbid  Anatomy. — The  heart  is  usually  large  and  infiltrated  with  fat, 
the  right  side  dilated  and  the  left  hypertrophied;  or  there  may  be  at- 
rophy of  the  muscular  structure  of  the  entire  organ.  The  lungs  are  usu- 
ally, small  the  liver  large  and  fatty ;  the  stomach  is  large  and  the  mus- 
cular coat  well  developed;  the  intestines  are  often  dilated;  the  spleen, 
kidneys,  and  lymph-glands  are  usually  small,  and  the  pancreas  hyper- 
trophied.   The  blood  often  contains  a  greatly  increased  quantity  of  fat. 


6o4  PRACTICE  OF  MEDICINE 

Symptoms. — The  appearance  is  too  well  known  to  require  description, 
except  for  the  fact  that  the  individual  may  be  either  ruddy  or  pale  and 
anemic.  All  the  functions  of  the  body  may  be  carried  on  normally,  but 
there  are  usually  interruptions,  particularly  of  digestion.  The  bodily 
activity  is  impaired;  the  mind  may  be  sluggish  and  dull,  or  bright  and 
active.  Obesity  is  generally  progressive,  except  when  it  begins  in  early 
life ;  it  may  then  subside  at  puberty.  More  important  is  the  tendency  to 
disease,  and  the  diminished  power  of  resistance  which  it  entails.  Death 
may  occur  by  syncope  from  extreme  fatty  degeneration  of  the  heart, 
from  apoplexy  due  to  the  rupture  of  an  atheromatous  artery  in  the 
brain,  from  acute  pulmonary  congestion,  rupture  of  the  heart,  angina 
pectoris,  or  uremia. 

Treatment — The  general  indications  are  to  reduce  the  quantity  of 
carbohydrates  ingested  and  the  allowance  of  fluid;  alcohol  should  be 
forbidden.  The  change  should  not  be  too  suddenly  made,  or  carried  to 
the  extent  of  reducing  the  patient's  strength.  There  are  several  methods 
of  regulating  the  diet,  chiefly  by  limiting  the  quantity  of  fluid  and  ex- 
cluding certain  articles  of  food.  Banting's  method  consists  in  reducing 
the  quantity  of  all  kinds  of  food  to  an  extent  that  can  seldom  be  en- 
forced. It  permits  only  from  21  to  27  ounces  of  solids  in  a  day,  of 
which  13  to  16  ounces  consist  of  animal  food  and  only  2  ounces  of 
bread.  Sugar  and  other  starches  are  strictly  excluded.  Ebstein  restricts 
the  same  articles,  but  allows  fats,  because  they  produce  satiety  and 
diminish  thirst,  a  fact  observed  by  Hippocrates.  Oertel  strongly  objects 
to  the  free  allowance  of  fat  and  adopts  a  diet  consisting  of  lean  beef, 
veal,  or  mutton,  and  eggs,  with  green  vegetables,  and  a  limited  quantity 
of  fats  and  carbohydrates,  including  4  to  6  ounces  of  bread  daily.  The 
quantity  of  fluid  he  limits  to  6  oz.  of  tea,  coffee,  or  milk,  morning  and 
evening,  12  oz.  of  wine,  and  8  to  16  ounces  of  water  in  24  hours.  A 
most  important  part  of  his  treatment,  however,  consists  in  systematic 
forced  exercise,  particularly  mountain-climbing.  The  Weir  Mitchell  treat- 
ment confines  the  patient  to  bed  for  a  month  or  six  weeks  on  a  regu- 
lated milk  diet,  with  massage  and  the  Swedish  movement. 

Hot  baths,  massage,  and  active  exercise,  including  much  walking,  may 
be  employed  as  adjuncts  to  any  of  the  other  methods  which  do  not  in- 
clude them.  Among  drugs,  the  most  satisfactory,  perhaps,  is  the  thyroid 
extract  in  doses  of  gr.  v  (0.32)  t.  i.  d.,  but  it  fails  in  many  cases. 

Adiposis  Dolorosa. — An  affection  of  middle  age,  characterized  by  an 
irregular,  symmetrical  deposit  of  fatty  masses  in  various  regions  of  the 
body,  preceded  or  attended  with  pain.  The  disease  was  first  described 
by  Dercum.  Large,  often  pendulous,  nodular,  encapsulated  masses  of 
reddish  fat  are  formed.  Nerve  fibers  run  over  the  nodules.  Paresthesias 
sometimes  develop.  The  nature  of  the  disease  is  not  definitely  known, 
but  atrophic  changes  in  the  thyroid  gland,  and  interstitial  neuritis,  have 
been  observed  in  cases,  and  improvement  has  followed  the  administration 
of  thyroid  extract. 


SECTION  IX. 
Intoxications  and  Miscellaneous  Diseases. 


ALCOHOLISM. 

INEBRIETY,   DRUNKENNESS. 

Definiiion. — An  acute  or  chronic  intoxication  due  to  excessive  indul- 
gence in  alcoholic  beverages. 

Eiiology. — i.  While  the  immediate  cause  of  acute  alcoholism  is  over- 
indulgence, there  are  many  influences  which  predispose  or  lead  to  it. 
Among  these  are  the  example  or  invitation  of  companions,  the  desire 
to  meet  the  demands  of  society,  to  cope  with  a  rival,  to  relieve  fatigue, 
anxiety,  melancholy,  grief,  or  pain.  In  most  instances  the  intoxication 
is  accidental,  for  the  individual  seldom  starts  with  the  intention  to  be- 
come drunken.  2.  Chronic  alcoholism  is  doubtless  largely  due  to  an 
inherited  neurotic  taint  or  instability  of  the  nervous  system.  Not  in- 
frequently a  more  or  less  continuous  line  of  inebriety  is  associated 
through  several  successive  generations  with  occasional  cases  of  hysteria, 
epilepsy,  or  insanity.  The  influence  of  example  is  also  strong;  but  it 
often  happens  that  the  remembrance  of  a  drunken  parent  stimulates 
the  children  to  abstinence.  The  inherited  tendency  may  crop  out,  how- 
ever, in  the  third  generation.  The  use  of  alcohol  as  a  medicine  in  acute 
diseases  has  seldom  begotten  a  fondness  for  it,  but  the  physician  should 
be  guarded  in  advising  its  use  as  a  tonic.  Other  predisposing  causes  are 
occupations  requiring  the  handling  of  liquors,  overwork,  idleness,  and 
other  forms  of  debauchery. 

Symptoms.— (^1^  Acute  Alcoholism.— The  first  effect  of  the  ingestion 
of  a  large  quantity  of  alcohol  is  usually  shown  in  an  increased  rapidity 
and  force  of  the  circulation.  The  face  becomes  flushed,  later,  perhaps, 
cyanotic ;  the  pulse  full  and  bounding,  and  the  respiration  deep  and  some- 
times irregular.  Nervous  phenomena  soon  follow.  There  is  at  first 
stimulation  of  the  centers  of  the  cortex  and  cerebellum.  The  ideas 
flow  rapidly,  but  later  they  become  confused,  and  finally  there  is  a  com- 
plete demoralization  both  of  common  and  of  special  sense.  Natural 
peculiarities  of  disposition  are  exaggerated,  and  the  individual  becomes 
obtrusive  in  his  friendship  or  quarrelsome  to  a  degree.  Muscular  inco- 
ordination soon  supervenes,  then  relaxation,  and  finally  narcosis.  While 
in  this  state,  the  drunken  person  is  unconscious  and  to  a,  great  extent 
anesthetic ;  but  he  can  almost  always  be  aroused  to  the  point  of  mut- 
tering answers  to  questions.  The  pupils  may  be  either  dilated  or  con- 
tracted, they  are  seldom  unequal.  The  temperature  is  reduced,  some- 
times to  several  degrees  below  normal,  even  to  90°,  85°  F.  (29.5°  C),  or 


6o6  PRACTICE  OF  MEDICINE 

less ;  the  respiration  may  become  stertorous.  The  breath  has  the  strong 
odor  of  alcohol.  Muscular  twitchings  are  not  uncommon,  but  convul- 
sions seldom  occur,  except  in  the  chronic  drunkard  or  after  the  ingestion 
of  an  enormous  quantity  of  alcohol.  Under  such  circumstances  the  con- 
vulsions may  be  fatal.  A  homicidal  mania  is  sometimes  induced.  The 
term  dipsomania  is  applied  to  the  habit  of  indulging  in  an  occasional 
spree,  especially  by  one  strongly  predisposed  to  inebriety. 

Diagnosis. — The  diagnosis  is  seldom  difficult,  but  serious  errors  are  the 
more  frequent  on  that  account.  The  alcoholic  coma  is  to  be  differen- 
tiated from  that  due  to  apoplexy,  uremia,  diabetes,  epilepsy,  opium,  and 
other  poisons.  In  most  cases  the  diagnosis  is  best  established  by  ex- 
amination of  the  stomach-contents.  The  odor  of  the  breath  and  con- 
dition of  the  pupils  are  alike  untrustworthy,  since  these  forms  of  coma 
frequently  occur  in  alcoholic  subjects. 

Apoplectic  coma  is  more  profound,  the  pupils  are  more  constantly 
unequal,  and  the  hemiplegic  relaxation  of  the  muscles  of  one  side  and 
deviation  of  the  tongue  may  be  recognizable.  Uremic  coma. — An  edema- 
tous face,  contracted  pupils,  muscular  twitchings,  and  convulsions  are 
common,  the  coma  is  profound,  and,  unless  the  individual  has  indulged 
in  alcohol,  the  odor  of  the  breath  is  ammoniacal.  The  urine  is  albu- 
minous, and  contains  casts.  Diabetic  coma  is  deep;  the  breath  may  be 
sweetish,  the  urine  contains  sugar.  Epileptic  coma  follows  a  seizure  the 
character  of  which  can  usually  be  recognized.  Opium  narcosis  is  char- 
acterized by  extremely  slow,  interrupted  respiration,  close  contraction 
of  the  pupils,  feeble  pulse  and  great  muscular  relaxation.  Other  drugs — 
absinth,  chloral,  ether,  chloroform — and  poisonous  gases  are  generally 
recognizable  by  their  odor  upon  the  breath  of  the  patient;  the  drug 
may  be  discovered  in  the  stomach-contents  or  in  the  urine. 

(2)  Chronic  Alcoholism. — This  condition  follows  either  constant  or 
periodic  excess,  but  more  rapidly  the  former.  The  effects  are  seen  for  the 
most  part  in  the  gastrointestinal  and  nervous  systems.  The  patho- 
logical changes  are  chiefly  of  a  sclerotic  character,  and  affect  especially 
the  liver  and  the  peripheral  nerves  (alcoholis  neuritis).  To  what  extent 
the  central  nervous  system  may  be  involved  has  not  been  fully  deter- 
mined. 

Digestive  System. — Chronic  gastritis  is  one  of  the  most  common  re- 
sults of  excessive  alcoholic  indulgence.  This  is  manifested  by  indigestion, 
nausea,  gastric  distress,  vomiting,  especially  in  the  morning,  anorexia, 
perverted  appetite,  furred  tongue,  and  foul  breath.  Constipation  usually 
accompanies  it.  Hepatic  cirrhosis  is  induced  in  a  variable  proportion 
of  cases,  but  especially  in  those  who  habitually  take  undiluted  whisky 
mto  an  empty  stomach. 

Symptoms. — Nervous  System. — The  manifestations  may  be  either  func- 
tional or  organic  in  character;  but  the  transition  from  functional  dis- 
turbance to  structural  change  is  an  insidious  one.  Among  the  func- 
tional symptoms  are  tremors  of  the  hands  and  tongue,  dullness  of  in- 
tellect, apathy,  forgetfulness,  disregard  of  duty,  irritability  of  temper, 
often  slovenliness,  and  sometimes  general  immorality  and  degradation. 
Periodical  hallucinations  may  occur.  Epilepsy  and  various  forms  of  in- 
sanity, especially  paralytic  dementia,  are  generally  regarded  as  possible 
results  of  chronic  alcoholism. 


ALCOHOLISM  607 

The  facies  of  the  toper  is  generally  characteristic.  His  eyes  are  watery, 
the  conjunctivge  congested,  the  nose  and  cheeks  are  reddened  by  the 
dilatation  of  superficial  veins,  producing  acne  rosacea,  the  countenance 
becomes  dull,  and  the  speech  slow  and  indistinct. 

Circulatory  System. — The  heart  of  the  chronic  drunkard  is  not  in- 
frequently dilated,  and  a  more  or  less  general  arteriosclerosis  is  almost 
uniformly  present  at  a  late  stage  of  the  disease.  The  extent  to  which 
the  kidneys  are  affected  by  alcohol  is  variously  estimated.  It  is  not 
unusual,  however,  to  find  them  normal.  Formad  has  described  an  en- 
largement, especially  in  the  transverse  diameter,  peculiar  to  excessive 
drinkers  of  beer. 

Delirium  Tremens  (^Mania  a  Potii).—T\\\'s>  affection  is  generally  only 
an  acute  disturbance  occurring  during  the  course  of  chronic  alcoholism, 
but  it  may  supervene  upon  a  debauch  or  occur  shortly  after  the  cessa- 
tion of  a  long-continued  excess.  Rarely  it  develops  from  a  single  spree, 
and  then,  as  a  rule,  in  one  given  to  excess.  Again,  it  is  sometimes  in- 
duced in  an  alcoholic  subject  after  weeks  of  abstinence,  by  the  receipt 
of  an  injury,  a  surgical  operation,  or  an  attack  of  illness ;  abstinence 
from  food  and  mental  distress  are  often  operative  factors. 

Symptoms. — The  attack  usually  begins  with  restlessness,  insomnia, 
fear,  and  suspicion.  Hallucinations  of  sight  and  hearing  soon  super- 
vene. Rats,  mice,  and  snakes,  often  of  brilliant  colors,  appear  upon  the 
wall  or  crawl  over  the  bed.  The  patient  is  often  busily  engaged  in  some 
imaginary  employment;  angels  or  demons  are  often  his  advisers  or  tor- 
mentors. In  an  unguarded  moment  he  often  tries  to  escape  from  his 
persecutors.  Muscular  tremors,  especially  of  the  hands  and  tongue,  are 
constant  features.  'The  patient  often  sinks  into  a  typhoid  state,  with 
elevation  of  temperature,  seldom  above  102°  or  103°  F.  (39.5°  C). 
The  pulse  is  rapid  and  soft,  and  the  tongue  becomes  heavily  coated. 
The  symptoms  subside  after  a  few  days,  or  the  strength  gradually  de- 
clines and  death  ensues  from  failure  of  the  circulation. 

Diagnosis. — The  condition  is  usually  readily  recognized  when  the  his- 
tory of  indulgence  is  known.  It  is  important,  however,  to  make  a  thor- 
ough examination,  particularly  of  the  lungs,  in  order  to  exclude  the  pres- 
ence of  pneumonia,  especially  in  the  apex.  Meningitis  is  not  infrequently 
suggested  by  the  condition.  Erysipelas  is  often  accompanied  with  de- 
lirium like  that  of  alcoholism. 

Treatment. — Sleep  is  generally  a  specific  in  acute  cases.  After  a  de- 
bauch, sleep  generally  comes  spontaneously.  In  delirium  tremens,  how- 
ever, it  must  be  induced  by  the  administration  of  drugs.  Chloroform 
may  be  cautiously  administered  in  a  violent  case.  Chloral  is  safer,  and 
should  be  combined  with  the  bromids,  gr.  xv.  (i.o)  of  the  former 
and  gr.  xxx  (2.0)  of  the  latter,  every  two  hours.  Small  doses  of  apo- 
morphin  (gr.  1-40;  0.0016)  every  hour  often  quiet  the  patient.  Hyos- 
cin  hydrobromate,  gr.  i-i 00  (0.0006)  hypodermically,  is  perhaps  better. 
Morphin  is  much  employed,  but  it  is  often  useless  and  never  free  from 
danger.    Two  or  three  doses  of  ^  grain  (0.016)  should  be  the  limit. 

When  the  case  is  seen  early,  lavage  of  the  stomach  is  indicated,  unless 
vomiting  has  occurred.  Milk  and  broths,  given  at  short  intervals, 
should  constitute  the  diet.  It  is  sometimes  necessary  to  administer  al- 
cohol to  support  the  heart  for  a  few  days,  and  strychnin  should  gener- 


6o8  PRACTICE  OF  MEDICINE 

ally  be  given.  When  the  temperature  is  low,  the  hot  pack  and  hot 
bottles  should  be  applied.  For  the  relief  of  the  gastric  irritability  and 
headache,  usually  following  a  debauch,  the  aromatic  spirit  of  ammonia 
should  be  given  in  half-dram  (2.0)  doses.  Blood-letting  is  recommended 
in  sthenic  cases  following  the  ingestion  of  a  large  quantity  of  alcohol. 

The  treatment  of  chronic  alcoholism  is  exceedingly  unsatisfactory. 
As  a  rule,  relapse  occurs  sooner  or  later.  In  a  few  cases,  when  there  is 
a  strong  desire  on  the  part  of  the  patient  to  reform,  prolonged  resi- 
dence in  a  sanitarium  is  effectual;  but  in  the  absence  of  determination 
and  more  than  ordinary  will-power,  treatment  is  useless.  The  "  drug- 
ging" of  the  patient's  liquor  with  apomorphin  or  tartar  emetic  is  occa- 
sionally successful  in  producing  a  temporary  disgust  for  drink.  The  hypo- 
dermic administration  of  small  doses  of  atropin,  apomorphin,  and  strych- 
nin, but  more  particularly  of  hyoscin  hydrobromate,  is  said  to  have  a 
similar  effect.  When  circumstances  will  permit,  a  permanent  removal  to 
new  scenes,  and  a  careful  selection  of  new  associates,  or  continued  travel 
in  the  companionship  of  persons  capable  of  giving  moral  support  to  the 
patient's  feeble  determination,  are  sometimes  productive  of  good  results. 

MORPHINISM. 

MORPHIA  HABIT,   MORPHINOxMANIA,  OPIUM  HABIT. 

Definition. — A  chronic  intoxication  with  morphin  or  one  of  the  other 
derivatives  of  opium. 

Eiiology. — In  a  majority  of  cases,  in  this  country  at  least,  the  habit 
is  acquired  through  the  prolonged  use  of  the  drug  for  the  relief  of  pain 
or  insomnia,  or  to  quiet  alcoholic  nervousness.  It  is  most  readily  ac- 
quired from  hypodermic  administration.  The  habit  is  prevalent  to  a  sur- 
prising degree  among  physicians  and  druggists,  and  a  majority  of  the 
other  habitues  are  women.  It  is  very  rarely  deliberately  developed  for 
the  supposed  pleasure  of  it,  but  in  the  nether-world  it  is  often  adopted 
simply  as  an  additional  mode  of  dissipation.  Morphin  is  taken  hypo- 
dermically,  laudanum  and  paregoric  are  drunk,  and  occasionally  opium 
is  smoked  in  the  same  manner  as  in  the  Orient.  The  same  difference 
of  susceptibility  is  observed  as  in  alcoholism.  Some  persons  give  up  the 
drug  without  difficulty  after  using  it  constantly  as  a  medicine  for  many 
months,  while  others  develop  a  craving  for  it  almost  frorn  the  beginning. 
Those  who  inherit  an  alcoholic  tendency  are  the  surest  victims. 

Symptoms. — For  a  short  time  the  drug  produces  a  feeling  of  exhilara- 
tion, a  pleasant  freedom  from  worry  and  care;  but  this  is  soon  lost, 
and  an  increased  indulgence  is  essential  to  even  moderate  comfort.  As 
the  effect  of  a  dose  begins  to  wear  off,  a  feeling  of  weakness  and  mental 
depression,  often  accompanied  with  gastric  distress  and  nausea,  comes 
over  the  victim,  and  unless  another  dose  is  taken,  he' becomes  nervous, 
irritable,  cold,  and  tremulous.  The  continued  use  of  it  develops  an  ap- 
pearance which  is  characteristic.  There  is  progressive  emaciation ;  the 
face  becomes  sallow,  often  -wTinkled  and  prematurely  aged.  The  pupils 
are  contracted  to  the  size  of  a  pin-point  when  under  the  influence,  or 
widely  dilated,  irregular,  and  changeable  when  deprived,  of  the  drug. 
Itching,  especially  of  the  nose,  is  commonly  a  symptom.    The  tongue  is 


COCAIN  HABIT  609 

dry,  and  the  lips  must  be  frequently  moistened;  the  speech  becomes 
slow  and  drawling,  and  old  habitue's  are  not  infrequently  overcome 
with  drowsiness,  even  in  the  midst  of  conversation.  Sleep  is  often  dis- 
turbed. The  muscles  twitch,  and  the  limbs  sometimes  assume  positions 
suggestive  of  catalepsy.  Profound  hysteria  or  neurasthenia  is,  in  fact, 
often  developed  in  women.  Chills  sometimes  occur,  and  the  tremor  and 
•excitement  occasioned  by  deprivation  of  the  drug  may  amount  almost 
to  mania.  The  quantity  required  by  different  habitues  is  not  the  same. 
Some  never  exceed  5  or  6  grains  a  day,  while  others  rapidly  increase 
the  dose  to  20,  even  40,  or  more  grains.  In  some  instances,  as  in  al- 
coholism, a  moderate  quantity  is  taken  continuously,  and  a  large  dose 
is  indulged  in  occasionally.  The  patient's  statements  can  seldom  be 
relied  upon  in  regard  to  the  quantity  taken,  for  in  most  cases  they  be- 
come utterly  untruthful.  The  duration  of  the  habit  is  also  variable. 
In  Oriental  countries  the  drug  has  apparently  little  effect  upon  the 
health,  and  it  is  often  tolerated  for  many  years.  In  other  instances  a 
fatal  decline  of  strength  is  early  induced  by  it. 

Treatment. — The  physician  in  general  practice  is  seldom  justified  in 
attempting  to  cure  the  habit.  What  can  be  accomplished  with  safety 
and  almost  certainty  in  a  sanitarium  is  extremely  difficult  and  often 
dangerous  elsewhere.  The  patient  must  be  removed  from  the  possibility 
of  securing  a  supply  of  the  drug.  The  method  usually  employed  is  the 
gradual  withdrawal  of  the  morphin.  The  doses  must  be  given  at  exact 
intervals,  about  four  a  day,  and  each  day  less.  The  greatest  difficulty 
is  experienced  in  the  final  withdrawal.  Atropin  in  sufficient  doses,  to 
produce  extreme  dryness  of  the  mouth  and  throat  and  other  physio- 
logical effects,  is  an  aid  at  this  time.  During  the  treatment  the  patient 
should  receive  the  most  nourishing  food  at  regular  intervals,  and  of  a 
character  depending  upon  the  condition  of  the  digestion.  The  aching 
pains,  sleeplessness,  and  general  nervousness  that  usually  occur  toward 
the  end  of  treatment  are  best  relieved  by  hot  baths  and  massage.  Trional 
may  be  required  at  night  in  doses  of  20  or  30  grains  (1.30 — 2.0).  A 
new  treatment  has  been  advocated  by  Lott  of  Texas,  and  supported  by 
Hare  and  others.  It  consists  in  the  administration  of  large  doses  of 
hyoscin  hydrobromate,  even  gr.  ^/(  (0.015)  in  each  twenty-four  hours, 
and  the  immediate  withdrawal  of  the  morphin.  The  patient  often  de- 
velops alarming  symptoms,  but  recovers  without  a  craving  for  the 
drug.  Pettey  has  shown  that  the  treatment  is  extremely  dangerous 
in  some  cases,  and  that  in  another  group  it  is  efficient  in  much  smaller 
dosage  than  recommended  by  Lott,  providing  the  intestine  be  thor- 
oughly evacuated  by  free  purgation  before  its  administration  is  begun. 
The  treatment  has  not  yet  been  extensively  employed.  After  recovery 
the  patient  should  remain  for  several  months  away  from  home.  A  change 
of  residence  is  often  advantageous  in  removing  old  suggestions  of  the 
habit. 

COCAIN  HABIT. 

The  cocain  habit  is  becoming  prevalent,  especially  among  the  negroes 
and  lowest  class  of  whites.  It  is  most  frequently  taken  in  the  form  of 
snuff,  sometimes  hypodermically.    Before  its  dangers  had  been  recognized, 

39 


6io  PRACTICE  OF  MEDICINE 

many  individuals  acquired  the  habit  from  the  use  of  sprays,  ointments^ 
and  solutions  for  the  nose,  throat,  or  eye.  The  effect  of  a  large  dose 
is  often  maddening,  but  prostration  ensues,  and  the  individual  lies  for 
several  hours  in  an  unconscious  state.  Hallucinations  of  sight  and  hear- 
ing are  commonly  induced.  The  pupils  are  dilated,  nystagmus  is  com- 
mon. The  pulse  is  rapid  and  feeble.  The  continued  use  of  the  drug 
produces  the  utmost  depravity.  The  appearance  is  not  always  distinc- 
tive. The  inflamed  and  often  ulcerated  condition  of  the  nose,  the  black- 
ness of  the  tongue  and  teeth,  the  anemic  appearance,  and  restlessness  of 
the  eyes  will  generally  suggest  the  use  of  the  drug. 

Treatment. — The  management  of  the  case  is  practically  the  same  as 
that  of  the  morphin  habitue. 

CHLORAL  HABIT. 

This  habit  is  acquired  in  much  the  same  manner  as  that  of  morphin. 
It  is  less  common  than  either  morphinism  or  cocainism. 

The  effect  of  the  drug  is  less  exhilarating,  and  the  ultimate  effect 
is  profound  depression,  anemia,  and  tremor  of  the  hands.  The  patient  is 
nervous,  irritable,  morose,  and  may  finally  become  demented.  Indiges- 
tion and  diarrhea  are  common,  the  breath  is  fetid,  and  the  tongue 
heavily  coated.  Erythema  and  other  cutaneous  eruptions  are  common, 
the  general  integument  is  dry  and  blanched.  As  in  other  habits,  the 
moral  sense  is  obtunded. 

The  treatment  consists  in  the  withdrawal  of  the  drug  either  gradually 
or  at  once,  and  the  administration  of  bromids  in  large  doses,  hyoscin, 
and  tonics,  particularly  strychnin  and  iron.  The  treatment  is  more 
easily  accomplished  in  an  institution  for  the  treatment  of  inebriety. 

LEAD-POISONING. 

PLUMBISM,   SATURNISM. 

Etiology. — The  disease  may  be  produced  by  the  slow  intoxication 
of  the  system  with  lead.  The  disease  occurs  most  frequently  among 
artisans — those  handling  lead  in  any  form,  from  the  smelter  to  the 
painter  and  glazier.  Miners  are  seldom  affected.  The  lead  may  be 
absorbed  through  the  respiratory  passages,  the  digestive  tract,  or  the 
skin.  In  the  smelting  of  the  ore,  the  grinding  of  white  lead,  and  the 
mixing  of  paint,  the  poisoning  arises  probably  both  from  the  inhalation 
and  swallowing  of  the  dust  or  fumes.  Among  painters,  glaziers,  plumb- 
ers, and  the  like,  it  is  largely  a  matter  of  carelessness  in  eating  with 
unwashed  hands.  Poisoning  sometimes  results  from  drinking  water, 
wine,  or  cider  which  has  passed  through  new  lead  pipes  or  that  has  been 
stored  in  lead-lined  tanks.  Women  are  often  very  susceptible  to  the  poison, 
and  have  been  affected  through  the  use  of  cosmetics,  hair-dyes,  false 
teeth,  or  by  biting  lead-dyed  silk  thread. 

Morbid  Anatomy. — The  lead  becomes  deposited  more  or  less  generally 
in  the  soft  tissues  of  the  body,  but  especially  in  the  muscles,  nerves,  and 
mucous  membranes.  Slow  elimination  takes  place  through  the  skin, 
kidneys,  liver,  and  salivary  glands.    The  muscles  become  pale,  atrophied, 


LEAD-POISONING  6ii 

and  sometimes  indurated  with  fibrous  tissue.  Parenchymatous  neuritis 
is  also  found  most  markedly  in  the  peripheral  ends  of  the  nerves,  and  the 
nerve-endings  in  the  muscles  are  degenerated.  Sclerosis  of  the  arteries, 
liver,  and  kidneys  is  found  in  advanced  cases. 

Symptoms. — The  manifestations  of  lead-intoxication  usually  follow 
long  exposure,  but  in  some  instances  they  have  developed  after  exposure 
of  only  a  few  weeks,  or  even  of  only  a  few  days'  duration.  Rapid  poi- 
soning is  more  common  as  a  result  of  the  inhalation  of  the  fumes  of 
smelting-furnaces,  the  dust  from  the  grinders  and  mixers,  or  that  from 
sand-papering  in  paint-shops.  The  symptoms  may  be  either  acute  or 
chronic  in  character. 

Acute  Symptoms. — Cases  are  occasionally  encountered  in  which  the  vio- 
lence of  the  poisoning  resembles  that  caused  by  the  taking  of  a  large 
dose  of  one  of  the  soluble  salts  of  lead,  intense  pain  in  the  abdomen, 
vomiting,  and  diarrhea.  As  a  rule,  however,  the  more  rapid  intoxica- 
tion is  shown  by  a  rapidly  developing  anemia,  peripheral  neuritis,  some^ 
times  accompanied  with  convulsions  and  delirium.  Severe  gastrointes- 
tinal symptoms  are  equally  common.  Obstinate  constipation  develops, 
and  the  patient  is  suddenly  seized  with  a  violent  cramp  in  the  abdo- 
men (painters'  colic).  The  wall  of  the  abdomen  is  usually  retracted, 
and  there  is  a  feeling  as  though  the  intestine  was  being  twisted  into  a 
knot  beneath  the  umbilicus.  The  paroxysm  may  continue  almost  con- 
stant for  several  hours,  or  it  may  be  intermittent.  In  the  intervals 
there  are  moderate  pain  and  tenderness.  Vomiting  sometimes  occurs. 
The  temperature  may  be  subnormal.  The  urine  is  usually  scant  and 
albuminous.  Such  attacks  may  recur  at  intervals  for  months  and  years, 
especially  when  the  patient  continues  to  work  in  lead.  Death  may, 
however,  occur  within  the  first  two  weeks,  rarely  even  in  the  first  attack, 
especially  in  an  individual  who  has  been  overwhelmed  by  a  short  ex- 
posure to  lead.  Acute  lesions  of  the  central  nervous  system  are  not 
common,  but  hemiplegia  has  been  attributed  to  an  exposure  of  only 
three  days. 

Chronic  Symptoms. — The  most  typical  symptoms  are  those  of  a  chronic 
character,  the  most  distinctive  of  which  are  anemia,  paralyses,  the  de- 
posit of  lead  in  the  gums,  and  encephalopathies. 

(i)  Afiemia^  or  the  saturnine  cachexia,  is  characterized  by  emacia- 
tion, deep  pallor,  sometimes  a  yellowish  hue,  and  dryness  of  the  skin. 
The  blood-count  shows  a  decrease  of  the  red  corpuscles  seldom  reaching 
50  per  cent,  with  corresponding  reduction  of  the  hemoglobin  and  a 
granular  degeneration  of  the  erythrocytes. 

(2)  A  blue  line  in  the  gums,  which,  when  present,  is  one  of  the  most 
valuable  diagnostic  signs.  It  is  due  to  the  formation  of  lead  sulphid, 
and  is  best  seen  along  the  margin  of  the  lower  gum  as  an  indigo-blue 
line,  which  cannot  be  removed  by  cleansing.  It  usually  forms  early,  and 
may  persist  indefinitely  or  it  may  shortly  disappear. 

(3)  Lead-Palsy. — Several  forms  of  lead-paralysis  occur  as  a  result 
of  a  peripheral  neuritis.  The  most  common  is  :  («)  That  known  as  wrist- 
drop, or  the  antibrachial  type.  When  the  arms  are  extended,  the  hands 
and  fingers  droop  and  cannot  be  raised  through  the  action  of  the  ex- 
tensor muscles.  It  is  due  to  aff"ection  of  the  musculospiral  nerve.  Less 
frequent    forms    are :    (/;)  The   brachial,   in   which    the    scapulohumeral 


6i2  PRACTICE  OF  MEDICINE 

is  involved,  producing  paralysis  of  the  deltoid,  biceps,  brachialis  anticus, 
and  rarely  of  the  pectorals.  It  may  follow  wrist-drop,  but  is  occasion- 
ally a  primary  affection ;  (.f)  The  Aran-Duchenne  form,  which  may  closely 
resemble  poliomyelitis  anterior  chronica,  affecting  the  small  muscles  of 
the  hands,  and  producing  marked  atrophy,  especially  of  the  thenar 
and  hypothenar  eminences.  In  some  instances  the  muscular  atrophy  is 
the  primary  change ;  (^/)  the  peroneal  form,  affecting  the  muscles  of  the 
lower  extremities,  especially  the  lateral  peroneals  and  extensors  of  the  big 
toe.  The  steppage  gait  is  produced.  (^)  A  rare  form  in  which  the  ad- 
ductors of  the  larynx  are  involved. 

Cramps  sometimes  occur  in  the  affected  muscles  or  in  the  flexed  joints 
(lead-arthralgia),  and  tremors,  increased  by  muscular  effort,  are  not 
unusual.  Sensation  may  not  be  altered.  Rarely  there  is  a  general 
paralysis  which  slowly  or  rapidly  extends  to  all  the  muscles  of  the  ex- 
tremities, resembling  an  ascending  spinal  paralysis.  The  diaphragm 
may  be  involved,  with  fatal  result.  A  febrile  form  also  has  been  recog- 
nized.   The  electrical  reaction  of  degeneration  is  usually  present, 

(4)  Cerebral  Symptoms  (Lead-Encephalopathy). — These  may  be  purely 
functional  or  they  may  depend  upon  structural  lesions,  particularly  end- 
arteritis of  the  cerebral  vessels.  Manifestations  of  a  hysterical  nature 
are  common  in  women ;  convulsions  may  occur,  or  epilepsy  may  develop. 
Acute  delirium  with  hallucinations  may  occur  independently  or  alternat- 
ing with  convulsions. 

(5)  Arteriosclerosis  is  frequently  produced,  especially  in  the  kidneys, 
and  hypertrophy  of  the  heart  may  follow  it. 

(6)  Saturnine  gout  is  occasionally  observed,  especially  in  England. 
It  is  believed  that  the  presence  of  lead  favors  the  deposit  of  urates  in 
the  tissue  of  the  joints. 

Diagnosis.— The  history  of  the  case  seldom  leaves  doubt  in  the  diag- 
nosis. Lead-colic  is  to  be  distinguished  from  that  of  volvulus  or  ap- 
pendicitis, and  from  renal  and  hepatic  colic.  This  is  usually  not  diffi- 
cult, on  account  of  the  retraction  of  the  abdomen  and  the  peculiar  sense 
of  constriction  at  the  umbilicus,  the  absence  of  tumor  or  fecal  vomiting 
and  the  subnormal  temperature.  The  pain  is  not  of  the  sharp,  cutting 
character  of  hepatic  and  renal  colic,  and  it  is  confined  to  the  umbilical 
region,  as  a  rule.  Alcoholic  neuritis  is  distinguished  from  that  due  to 
lead  by  the  presence  of  sensory  disturbances  and  the  more  usual  affec- 
tion of  the  lower  extremities. 

Prognosis. — This  is  favorable  in  a  majority  of  cases.  When  the  symp- 
toms develop  with  violence  after  short  exposure,  it  is  often  less  favor- 
able than  in  the  more  chronic  cases.  Atrophy  of  the  muscles  and  the 
reaction  of  degeneration  are  unfavorable  indications.  The  cerebral  dis- 
turbances sometimes  become  permanent.  Persistent  treatment  of  the 
paralysis  is  often  followed  by  surprisingly  good  results. 

Treatment. — Prpphy lactic  measures  should  be  adopted  by  all  workers 
in  lead.  Respirators  are  in  a  measure  beneficial  to  those  working  in  the 
smelting-works  and  where  lead  is  grovmd  or  mixed.  The  greatest  care 
should  be  taken  in  the  cleansing  of  the  hands,  including  the  nails.  The 
colic  requires  the  hypodermic  injection  of  morphin  and  the  application 
of  hot  stupes.  The  constipation  should  be  overcome  by  repeated  dram 
doses  of  magnesium  sulphate,  which  serves  also  to  render  the  lead  in- 


ARSENICAL  POISONING  613 

soluble.  The  elimination  of  the  lead  from  the  tissues  is  favored  by  po- 
tassium iodid  in  doses  of  gr.  v  to  x  (0.30 — 0.60).  It  should  not  be 
given  in  the  more  violent  cases,  or  until  it  is  probable  that  all  of  the 
metal  has  been  removed  from  the  intestine.  The  action  of  the  kidneys 
should  be  maintained  by  the  drinking  of  a  large  quantity  of  water. 
For  the  paralysis,  galvanic  and  faradic  electricity  may  be  employed, 
with  massage  of  the  muscles.  Iron  and  strychnin  are  also  indicated  for 
the  anemia  and  to  restore  muscular  tone.  The  effect  of  the  strychnin 
is  more  pronounced  and  more  rapid  when  the  drug  is  injected  into  the 
paralyzed  muscles. 

ARSENICAL   POISONING. 

Etiology. — The  poison  may  enter  the  system  either  through  ingestion 
or  through  inhalation.  Poisoning  is  not  infrequently  developed  among 
artisans  in  the  manufacture  of  glazes  and  colors  for  paper  and  other 
fabrics.  The  red  and  green  colors  of  wallpaper,  artificial  flowers,  car- 
pets, and  draperies  are  the  most  likely  to  contain  arsenic.  Through  the 
action  of  moisture  or  certain  molds  the  poison  may  be  liberated  in  the 
air.  Poisoning  has  been  contracted  also  through  the  sorting  of  playing- 
cards  and  other  glazed  paper,  curing  skins  by  the  taxidermist,  and  in 
the  manufacture  of  stained  glass.  Paris  green  is  a  frequent  source  of 
poisoning  to  farmers,  who  use  it  as  an  insect-poison.  A  case  is  occasion- 
ally met  with  in  which  the  prolonged  use  of  arsenic  as  a  medicine  has 
produced  toxic  effects.  There  is  a  great  difference  in  individual  sus- 
ceptibility. The  arsenic  habit  is  sometimes  contracted,  especially  by  the 
Austrian  peasants,  who  take  as  much  as  eight  grains  daily  without  seri- 
ous effects. 

Morbid  Anatomy. — A  degenerative  peripheral  neuritis  is  commonly 
found,  associated  with  a  similar  change  in  the  anterior  horns  of  the 
spinal  cord.  A  granular  degeneration  of  the  viscera  is  often  produced, 
especially  in  the  liver  and  kidneys. 

Symptoms. — Edema  of  the  eyelids,  and  conjunctivitis  with  headache, 
vertigo,  attacks  of  nausea,  mental  depression  or  hysteria,  are  the  symp- 
toms which  usually  first  attract  attention.  Anemia,  with  more  or  less 
emaciation,  is  a  constant  symptom.  The  mucous  membranes  of  the  nose 
and  throat  are  generally  dry  or  inflamed,  especially  if  the  poison  has 
entered  with  the  respired  air.  The  skin  is  dry,  the  hair  falls  out,  and 
there  may  be  pigmentation  or  bronzing,  eczema,  herpes,  or  urticaria. 
The  arsenic  may  be  found  in  the  secretions,  especially  in  the  urine. 
Albumin  and  casts  are  also  present,  and  sometimes  blood-corpuscles. 
Arsenical  paralysis  is  sometimes  developed ;  it  is  a  progressive  and  pain^ 
ful  neuritis  affecting  in  the  beginning  the  extensors  and  peronei  muscles 
of  the  legs  and  foot,  and  sometimes  involving  later  the  arms.  Tremors 
and  contractures  of  the  muscles  and  the  steppage  gait  are  usually  pro- 
duced. 

Diagnosis. — Lead-neuritis  is  distinguished  by  the  history,  the  blue 
line  in  the  gums,  and  generally  by  the  primary  affection  of  the  arms. 
Alcoholic  neuritis  can  generally  be  recognized  by  the  history  and  appear- 
ance of  the  patient;  the  face  is  flushed,  not  pale,  and  generally  an  acne 
rosacea  appears. 


6i4  PRACTICE  OF  MEDICINE 

Treatment. — The  source  of  the  poisoning  must  be  removed;  the  occu- 
pation of  the  patient  changed,  perhaps.  In  early  cases  this  is  soon  fol- 
lowed by  recovery.  The  patient  should  drink  freely  of  water  in  order 
to  favor  the  elimination  of  the  poison.  Further  than  that  the  treat- 
ment is  symptomatic.  Galvanism  and  massage  are  beneficial  for  the  neu- 
ritis. 

FOOD-POISONING. 

BROMATOTOXISMUS. 

1.  Ptomain-Poisoning. — This  is,  perhaps,  the  most  common  form  of 
food-poisoning  encountered  in  our  country.  The  nature  of  these  poi- 
sonous alkaloids  has  been  described  on  page  35.  They  may  be  formed 
in  the  food  before  it  has  entered  the  body,  or  afterward  in  the  intestine. 
Some  ptomains  are  extremely  toxic,  others  are  harmless.  The  poison 
is  to  some  extent  destroyed  by  cooking. 

2.  Meat-poisoning  (kreotoxismus)  is  produced  by  eating  pork,  sau- 
sage of  various  kinds  (botulismus  or  allantiasis),  and  occasionally  from 
beef,  veal,  or  mutton.  Although  the  poisonous  ingredient  is  in  most  in- 
stances due  to  a  form  of  decomposition,  it  is  not  known  to  be  identical 
with  any  of  the  ptomains.  Its  nature  is,  in  fact,  not  known.  Such 
intoxication  has  repeatedly  followed  the  eating  of  canned  meat,  but  in 
some  such  cases  the  poisoning  has  been  attributed  to  a  metallic  poison. 
The  meat  of  wild  animals  and  birds  is  sometimes  rendered  poisonous 
by  their  food. 

Symptoms. — The  symptoms  usually  develop  within  six  hours  after 
the  poison  has  been  ingested.  WTien  due  to  a  ptomain  formed  within 
the  body,  they  may  be  delayed  as  long  as  forty-eight  hours  or  more. 
The  first  indication  is  often  a  chilliness  or  pronounced  rigor,  followed 
by  nausea,  vomiting,  griping  pains  in  the  abdomen,  with  vertigo,  ex- 
treme prostration,  cold  perspiration,  and  great  thirst.  Diarrhea  is  gen- 
erally present  and  may  be  severe.  Fever,  101°  toio3°F.  (38°— 39.5°  C), 
is  common  and  may  last  for  several  days.  The  pulse  becomes  rapid 
and  feeble,  dyspnea  may  be  urgent.  An  intense  pain  is  sometimes  felt  in 
the  chest  or  between  the  shoulders.  The  tongue  is  heavily  coated,  often 
brown,  with  red  tip  and  edges.  The  stools  are  offensive.  Cramps  in 
the  extremities,  twitching  of  the  face-muscles,  prickling  and  tingling 
of  the  fingers,  and  psychical  disturbances  or  stupor  characterize  some 
cases.  Fatal  cases  are  usually  attended  with  collapse,  like  that  of  cholera, 
with  extreme  coldness  of  the  surface  and  rapid  shrinking  of  the  tissues. 

3.  Milk-Poisoning  (Galactotoxismus). — This  is  due  to  the  develop- 
ment of  poisons  by  bacteria  in  milk,  and  it  is  most  frequently  encoun- 
tered in  infants.  Cream,  ice-cream,  and  cheese  are  often  poisonous 
from  the  presence  of  the  t3^rotoxicon  of  Vaughan,  or  even  more  fre- 
quently from  the  presence  of  other  poisons  not  }'et  identified.  The 
symptoms  are  those  of  acute  gastroenteritis,  and  do  not  materially 
differ  from  those  of  ptomain  and  meat-poisoning. 

4.  Poisoning  by  Fish  (Ichthyotoxismus)  and  Shellfish— (^r)  Two 
forms  of  fish-poisoning  are  recognized.  One  is  due  to  a  poison  secreted 
by  glands  of  the  fish,  especially  the  sturgeon  of  Russia,  the  barb  of 
Europe,  and  the  tetrodon  of  Japan.    The  other  is  produced  by  the  bac- 


FOOD-POISONING  615 

teria  of  putrefaction.  The  symptoms  are  those  of  intense  disturbance 
of  the  gastrointestinal  tract,  nausea,  vomiting  and  diarrhea,  some- 
times accompanied  with  profound  nervous  prostration  and  weakness. 
Death  sometimes  occurs  within  a  few  hours. 

((^)  Mussel-Poisoning  (Mytilotoxismus).— This  form  of  intoxication 
is  attributed  by  Brieger  to  a  ptomain  found  chiefly  in  the  liver  of  the 
mussel;  cooking  does  not  destroy  it.  The  symptoms  are  acute  and  often 
fatal.  They  are  almost  solely  due  to  the  effect  of  the  poison  on  the 
nervous  system,  and  consist  of  numbness,  extreme  weakness,  with  rapid, 
feeble  pulse,  dilated  pupils,  subnormal  temperature,  and  finally  collapse. 
Vomiting  and  diarrhea  occur  in  some  cases.  Owing  to  idiosyncrasy, 
some  persons  are  poisoned  by  eating  oysters  or  clams.  In  such  cases 
there  is  usually  gastrointestinal  disturbance,  and  often  an  eruption  of 
erythema  or  urticaria. 

The  treatment  of  all  these  conditions  is  alike.  Vomiting  and  diar- 
rhea are  to  be  encouraged,  until  it  becomes  evident  that  they  no  longer 
serve  a  beneficial  purpose  in  removing  the  poison.  In  case  they  do  not 
occur,  the  stomach  should  be  washed  out  or  an  emetic  administered, 
followed  by  a  purge.  The  further  treatment  is  symptomatic.  Stimu- 
lants are  generally  required  for  the  prostration  and  feebleness,  morphin 
to  arrest  the  diarrhea  and  quiet  the  nervous  manifestations. 

5.  Grain- Poisoning  (Sitotoxismus). — This  was  formerly  of  frequent 
occurrence  in  some  parts  of  Europe,  but  it  is  almost  unknown  in  the 
United  States.    It  may  occur  under  several  forms  : 

(<?)  Ei'gotism  is  due  to  the  use  of  meal  or  flour  made  from  spurred 
grain,  a  condition  produced  by  the  fungus  claviceps  purpurea.  Two 
forms  of  ergotism  are  recognized,  one  gangrenous  and  attributed  to  the 
action  of  sphacelinic  acid,  the  other  nervous  and  attributed  to  cornutin. 
In  the  gangrenous  form  the  necrosis  affects  the  fingers  and  toes,  occa- 
sionally the  ears  and  nose.  In  the  nervous  form  the  patient  complains 
for  a  week  or  two  of  headache  and  weakness,  and  is  then  seized  with 
severe  cramps  and  contractures  of  the  muscles.  The  arms  are  flexed 
and  the  legs  and  toes  are  extended.  The  spasms  recur  at  variable  in- 
tervals and  sometimes  last  for  several  hours,  or  even  many  days,  at  a 
time.  Delirium  or  melancholia  often  develops,  and  the  condition  may 
pass  into  dementia.  Convulsions  are  not  uncommon.  A  sclerosis  of  the 
posterior  columns  of  the  spinal  cord,  not  unlike  that  of  locomotor  ataxia, 
is  sometimes  produced.  Preceding  the  development  of  the  more  pro- 
nounced symptoms  in  either  form  of  the  disease,  the  patient  often  ex- 
periences a  sensation  of  itching  or  tingling  in  various  parts  of  the  body, 
especially  in  the  fingers  and  toes. 

(Ji)  Lathyrism  (Lupinosis). — A  form  of  poisoning  produced  through 
the  adulteration  of  flour  with  the  chick-pea  vetch  (Lathyrus  sativus).  It 
has  occurred  for  the  most  part  in  France,  Italy,  Algiers,  and  India. 
The  symptoms  are  much  the  same  as  those  of  the  convulsive  form  of 
ergotism. 

(r)  Pellagra  (maidismus),  poisoning  caused  by  the  eating  of  fer- 
mented, unripe  maize  or  Indian  corn.  It  is  seldom  seen  in  the  United 
States.  The  symptoms  are  indigestion,  weakness,  insomnia,  sometimes 
salivation  and  diarrhea,  with  an  erythematous  eruption,  followed  by 
dryness  of  the  skin,  sometimes  with  descjuamation  or  the  development 


6i6  PRACTICE  OF  MEDICINE 

of  furuncles.  In  the  more  severe  cases  pronounced  nervous  and  mental 
disturbances  may  be  developed,  as  a  gradual  paralysis  of  the  legs, 
melancholia,  or  a  suicidal  mania.  The  disease  may  last  several  months 
and  end  in  recovery;  or,  through  progressive  emaciation  and  debility, 
it  may  terminate  fatally. 

The  freafmenf  consists  in  a  change  of  diet  and  the  employment  of 
tonics.    The  addition  of  salt  to  the  meal  is  said  to  counteract  the  poison. 

Beriberi  has  been  attributed  to  poisoning  with  fermented  rice.  (See 
p.  98.) 

Mushroom-Poisoning. — Two  forms  of  poisoning  result  from  the  eat- 
ing of  poisonous  fungi,  one  acting  upon  the  gastrointestinal  canal, 
the  other  on  the  nervous  system.  The  gastrointestinal  form  is  charac- 
terized by  violent  vomiting  and  purging,  intense  thirst,  prostration 
sometimes  amounting  to  collapse,  and  a  peculiar  sense  of  constriction 
of  the  throat.  Fever  is  sometimes  present.  In  the  nervous  cases  the 
poisoning  is  usually  of  a  narcotic  character.  The  individual  is  first 
seized  with  a  vertigo,  confusion  of  vision,  and  muscular  weakness.  Rigid- 
ity and  spasms  may  supervene.  He  then  becomes  drowsy,  and  often 
passes  into  a  comatose  state,  from  which  he  cannot  be  aroused.  Re- 
covery is  the  rule,  but  many  fatal  cases  have  been  recorded.  The  treat- 
ment is  the  same  as  that  of  ptomain-poisoning. 

SUNSTROKE. 

INSOLATION,  HEATSTROKE,   THERMIC  FEVER,  SIRIASIS,  COUP  DE  SOLEIL. 

Definition. — A  condition  produced  by  exposure  to  excessive  atmos- 
pheric temperature. 

Efio/ogy. — Any  influence  which  reduces  the  power  of  resisting  the  in- 
fluence of  heat  may  be  a  predisposing  cause  of  sunstroke.  Prominent 
among  such  influences  are  fatigue,  privation,  loss  of  rest,  overeating, 
and,  above  all,  indulgence  in  alcohol.  A  previous  attack  increases  the 
susceptibility.  A  heavy  moist  atmosphere  favors  the  action  of  the 
high  temperature.  The  direct  cause  may  be  exposure  to  the  sun's  rays 
or  exposure  to  high  atmospheric  temperature  without  the  action  of  the 
sun's  rays.  The  former  gives  us  one,  the  latter  two  forms  of  prostra- 
tion. 

1.  Sunstroke  proper  usually  occurs  in  individuals  who  are  engaged  at 
hard  labor  in  direct  sunshine,  as  farmers,  masons,  bricklayers,  and  other 
outdoor  laborers.  The  cases  are  most  frequently  seen  in  considerable 
numbers  when  a  hot  wave  passes  over  the  country,  and  when  the  intense 
heat  is  accompanied  with  a  high  degree  of  atmospheric  humidity. 

2.  Heatstroke,  or  thermic  fever,  is  produced  by  a  high  temperature 
without  the  direct  action  of  the  sun's  rays.  It  attacks  especially  those 
who  are  confined  in  close  apartments,  as  engineers,  firemen,  molders, 
glass-blowers,  laundresses,  and  cooks.  Its  occurrence  is  much  more  fre- 
quent, however,  among  those  who  drink  freely  of  beer  and  whisky.  While 
sunstroke  occurs  only  in  the  daytime,  thermic  fever  may  occur  at  any 
time  of  day  or  night. 

3.  Heat-Exhaustion.— This  form  of  prostration  occurs  under  the  same 
conditions  as  the  preceding,  but  the  results  are  often  different,  a  sub- 
normal temperature  and  collapse  being  not  unusual. 


SUNSTROKE  617 

Morbid  /In atomy.— Rigor  mortis  develops  unusually  early  and  putre- 
factive changes  begin  almost  immediately.  Ecchymoses  and  extravasa- 
tions of  blood  are  found  in  the  skin  and  serous  membranes.  The  left 
ventricle  is  usually  firmly  contracted  and  the  right  dilated.  Intense 
venous  engorgement  is  found  in  the  cerebrum  and  in  the  cerebrospinal 
meninges,  sometimes  also  in  the  lungs  and  other  viscera.  The  con- 
junctivcC  are  congested.  Degenerative  changes  may  be  found  also  in 
the  liver  and  kidneys.  The  blood  is  fluid  and  dark,  and  the  corpus- 
cles show  no  tendency  to  form  rouleaux.  Van  Gieson  found  the  neurons 
of  the  entire  neural  axis  in  a  state  of  parenchymatous  degeneration 
similar  to  that  produced  by  autointoxication,  and  it  has  been  suggested 
that  the  condition  is  one  of  autointoxication  superinduced  by  excessive 
heat.  The  suggestion  has  also  been  made  that  it  is  an  acute  infection. 
The  toxicity  of  the  urine  is  increased,  and  the  sweat  and  blood-serum 
become  toxic  to  animals. 

Symptoms. — The  onset  is  generally  sudden;  occasionally, however, there 
are  such  premonitions  as  dizziness  and  pain  or  fullness  in  the  head. 
The  symptoms  are  usually  classified  to  correspond  to  types  of  prostra- 
tion; but  they  differ  for  the  most  part  in  severity,  and  in  the  presence 
or  absence  of  fever.  In  mild  cases  the  prostration  may  be  complete, 
yet  short  of  unconsciousness,  accompanied  with  headache,  vertigo,  and 
sometimes  a  transitory  delirium.  The  temperature  rises  to  101°  or  102° 
F.  (38.0° — 39.0°  C.)  for  a  few  hours,  but  later  subsides  and  may  be- 
come subnormal.  The  skin  is  often  cold  and  may  be  moist.  The  pulse 
is  accelerated,  but  feeble.  Nausea  and  vomiting  may  occur.  Recovery 
within  a  few  days  is  the  rule. 

In  severe  cases  the  prostration  is  more  extreme.  The  individual  falls 
as  though  he  had  received  a  blow  upon  the  head,  and  death  is  some- 
times almost  instantaneous,  or  it  may  be  delayed  for  a  few  hours. 
This  is  generally  observed  in  cases  of  true  sunstroke,  and  it  occurs  in 
those  who  are  compelled  to  disregard  the  premonitory  indications  of 
its  approach.  It  is  the  form  which  overtakes  the  soldier  on  a  forced 
march.  Sometimes  the  attack  is  a  little  less  sudden.  The  individual 
then  becomes  dizzy,  weak,  nauseated;  there  is  a  feeling  of  constriction 
of  the  head  or  an  intense  headache.  The  vision  becomes  colored  (chro- 
matopsia)  or  indistinct.  A  person  in  this  condition  sometimes  wanders 
for  several  hours  in  a  state  of  subconsciousness.  Finally  unconscious- 
ness supervenes  and  he  sinks  into  a  profound  coma.  The  temperature 
rapidly  rises  and  often  reaches  108°,  110°  F.  (42°— 43°  C),  or  higher, 
hence  the  name  thermal  fever.  The  pulse  is  rapid  and  tense,  or  slow, 
soft,  and  feeble.  The  respiration  is  labored,  often  sighing,  or  it  may  be- 
come stertorous.  The  skin  is  generally  dry  and  intensely  hot.  Sudden 
arrest  of  the  perspiration  is  often  a  premonitory  symptom.  Temporary 
dilatation  of  the  pupils  is  sometimes  observed,  but  it  is  usually  followed 
by  extreme  contraction.  There  is,  as  a  rule,  complete  relaxation,  but 
jerking  of  the  muscles  or  convulsions  may  occur.  In  fatal  cases  the 
pulse  becomes  more  and  more  feeble,  the  respiration  quick  and  irregular, 
or  of  a  Cheync-Stokes  character,  and  death  occurs  from  failure  of  both 
circulation  and  respiration.  Recovery  is  usually  foretold  by  a  return 
of  consciousness,  restoration  of  normal  respiration  and  circulation,  and 
a  subsidence  of  the  other  symptoms.    For  a  long  time,  however,   some- 


6i8  PRACTICE  OF  MEDICINE 

times  for  many  years,  the  individual  remains  highly  sensitive  to  heat, 
and,  unless  exposure  be  avoided,  a  repetition  of  the  attack  is  apt  to  occur. 

A  continued  thermic  fever,  Florida  fever  or  country  fever,  often  mis- 
taken in  the  South  and  in  tropical  countries  for  malaria  or  typhoid 
fever,  has  been  described  by  Guiteras. 

Diagnosis. — The  condition  is  readily  recognized,  as  a  rule,  since  the 
circumstances  under  which  the  prostration  occurs  and  the  appearance 
of  the  patient  are  distinctive. 

Prognosis. — The  mortality  of  severe  cases  is  great.  All  depends  upon 
the  promptness  with  which  treatment  can  be  instituted  and  the  energy 
with  which  it  is  carried  out,  providing  the  patient  is  robust  and  not 
too  deeply  alcoholic.  The  recovery  is  often  incomplete,  however,  and  the 
patient  is  left  for  a  long  time  in  a  vulnerable  condition  with  reference 
to  heat,  and  his  mental  and  physical  strength  are  often  much  impaired. 
Insanity  is  occasionally  a  sequel. 

Treatment. — The  best  prophylactic  measure  is  temperance  in  all  things 
during  the  torrid  season.  In  mild  cases  little  is  required  for  the  attack 
further  than  rest  in  a  sheltered  place,  sponging  with  cold  water,  and  fan- 
ning, if  there  be  no  breeze.  Stimulants  should  be  given  if  there  is  great 
weakness,  and  strychnin  and  aromatic  spirit  of  ammonia  are  better 
than  alcohol. 

In  severe  cases  the  first  indication  is  to  reduce  the  temperature.  The 
patient  should  be  immediately  placed  in  a  bathtub  containing  ice-water 
and  pieces  of  ice;  he  should  be  literally  packed  in  ice.  WTien  this  is  im- 
possible, the  entire  body  should  be  rubbed  with  ice.  An  enema  of  ice- 
water  will  assist  in  reducing  the  fever.  Patients  in  a  moribund  state 
are  often  saved  by  this  method.  In  the  country,  until  ice  can  be  secured, 
the  patient  may  be  stripped  in  a  sheltered  place  and  sprinkled  freely 
with  water  from  a  sprinkling-can  or  poured  from  buckets.  Antipy- 
retics may  be  employed  in  such  cases,  but  their  action  is  depressing 
^nd  too  slow  to  be  relied  upon. 


DISEASES  OF  THE  MUSCLES. 

MYOSITIS. 

Definition. — Inflammation  of  the  muscles.  Muscular  rheumatism, 
or  rheumatic  myositis,  is  considered  elsewhere.  A  form  of  myositis 
occurs  in  trichinosis,  and  suppurative  myositis  is  observed  in  pyemia 
and  in  localized  abscess-formations.  Two  forms  remain  for  considera- 
tion, namely,  infectious  myositis,  or  poliomyositis,  and  myositis  os- 
sificans progressiva. 

INFECTIOUS  MYOSITIS. 

Etiology. — Although  the  disease  has  been  regarded  as  infectious, 
no  specific  micro-organism  has  been  identified.  Wagner  has  suggested 
that  some  cases  are  to  be  regarded  as  instances  of  acute  progressive 
muscular  atrophy. 

Morbid  Anatomy. — The  muscles  become  swollen,  firm,  and  friable, 
owing  to  the  infiltration  of  small  round  cells  and  the  proliferation  of 


DISEASES  OF  THE  MUSCLES  619 

the  connective  tissue.  Hyalin  and  fatty  degeneration  are  generally  ob- 
served. 

Symptoms. — The  swelling  and  firmness  of  the  muscles  are  readily  recog- 
nized, and  the  surrounding  tissues  become  edematous.  Fever  and  enlarge- 
ment of  the  spleen  are  usually  present.  Pain  is  produced  by  motion, 
and  paresthesia  may  be  detected.  Dyspnea  is  produced  when  the  mus- 
cles of  respiration,  especially  the  diaphragm  (diaphragmitis),are  affected, 
and  deglutition  may  be  interfered  with. 

Diagnosis. — Trichinosis  is  excluded  by  the  absence  of  trichina  in  a 
fragment  of  muscle  removed  for  examination.  The  presence  or  absence 
of  eosinophilia  has  not  been  sufficiently  established  in  either  condition 
to  be  regarded  as  a  positive  indication. 

Prognosis. — The  disease  usually  terminates  fatally  after  two  or  three 
months,  from  interference  with  respiration  or  the  development  of  pneu- 
monia. A  purulent  infiltration  of  the  muscle,  with  consequent  sepsis, 
has  been  observed. 

Treatment  is  only  palliative. 

MYOSITIS  OSSIFICANS  PROGRESSIVA. 

This  is  an  exceedingly  rare  disease  in  which  the  muscles  are  ulti- 
mately converted  into  bony  tissue.  It  is  more  frequent  in  boys  about 
the  age  of  puberty.  The  process  usually  begins  in  the  neck  and  back, 
but  other  muscles  are  occasionally  involved,  including  the  heart.  The 
muscles  become  swollen  as  in  acute  myositis.  The  skin  becomes  red- 
dened and  a  slight  fever  develops.  After  the  acute  symptoms  subside, 
the  mviscles  remain  indurated  and  the  process  of  ossification  gradually 
progresses.  Motion  is  restricted  from  the  first,  and  complete  pseudo- 
ankylosis  follows. 

Prognosis. — The  disease  lasts  several  years  and  finally  terminates  fa- 
tally.   No  method  of  treatment  has  been  found  of  any  benefit. 

MYOTONIA  CONGENITA. 

Thomsen's  Disease. 

Definition. — A  congenital  condition  in  which  a  tonic  spasm  of  the  mus- 
cles follows  voluntary  motion. 

Etiology. — The  disease  is  rare  in  this  country,  less  so  in  Europe.  It 
is  hereditary  and  usually  follows  the  male  line  of  descent.  The  cause 
is  not  known. 

Morbid  Anatomy. — The  muscle  nuclei  are  greatly  increased  both  in 
size  and  number,  and  the  transverse  striations  are  obscured  by  a  finely 
granular  degeneration.  The  intermuscular  connective  tissue  is  normal 
or  proliferated.  Changes  in  the  terminal  nerve-plates  have  not  been 
fully  demonstrated. 

Symptoms. — The  disease  is  first  manifested  in  infancy.  The  muscles 
appear  large,  but  their  strength  is  deficient.  A  voluntary  eft'of  t,  a  sud- 
den change  of  temperature,  or  violent  emotion  induces  a  tonic  con- 
traction which  relaxes  but  slowly,  and  interferes  with  the  more  delicate 
movements.  The  muscles  of  the  face,  eyes,  larynx,  and  heart  are  not 
usually  involved,  but  the  diaphragm  may  be  affected.    The  reflexes  and 


620  PRACTICE  OF  MEDICINE 

sensations  remain  normal.  Brief  galvanic  or  faradic  stimulation  pro- 
duces normal  reaction,  but  the  maximum  is  reached  tardily  and  the 
relaxation  is  slow.  Contraction  is  excited  only  by  closure  of  the  circuit, 
not  by  opening  it  (Erb's  myotonic  reaction).  Tapping  upon  the  muscle 
also  excites  unusual  contraction. 

The  disease  is  incurable,  but  it  does  not  materially  impair  health. 
No  treatment  for  it  is  known. 

PARAMYOCLONUS  MULTIPLEX. 

This  is  an  affection  of  unknown  pathology  in  which  clonic  contrac- 
tions occur  constantly  or  in  paroxysms,  chiefly  in  the  muscles  of  the 
extremities.  By  some  writers  it  is  regarded  as  a  nervous  affection  allied 
to  chorea  or  hysteria.  A  hereditary  transmission  has  been  noted  in 
some  cases.  It  is  sometimes  associated  with  degeneracy.  It  has  been 
observed  most  frequently  in  males  after  violent  emotional  disturbances, 
as  fright,  or  after  prolonged  exertion  or  great  strain.  In  the  more 
violent  paroxysms  the  movements  may  be  extremely  rapid,  and  a  tremor 
sometimes  persists  in  the  intervals.  It  is  sometimes  impossible  to  keep 
the  patient  in  bed.  The  condition  is  not  influenced  by  treatment,  ex- 
cept in  hysterical  cases,  or  as  the  movements  may  be  quieted  by  mor- 
phin  and  other  narcotics. 


SECTION  X. 
Diseases  of  the  Nervous  System. 


DISEASES  OF  THE  NERVES. 


NEURITIS. 


Definition.  —Inflammation  of  a  nerve.  Neuritis  may  be  localized,  affect- 
ing a  single  nerve,  or  general,  involving  many  nerves.  General  neuritis 
is  called  also  multiple  neuritis  and  polyneuritis. 

Etiology.— The  causes  of  localized  neuritis  are :  {a)  Traumatism,  as 
by  blows,  wounds,  laceration  by  fractures  or  dislocations,  injury  by 
the  hypodermic  needle  or  the  fluid  injected,  prolonged  pressure  by  mus- 
cle, tumor,  or  clamps  used  in  operations;  (J?)  cold,  affecting  particu- 
larly the  facial  or  sciatic  nerve;  (^)  extension  of  inflammation  from 
contiguous  parts;  (<^)  toxins  in  the  blood,  or  the  unknown  influences 
of  such  diseases  as  syphilis  and  leprosy. 

Multiple  neuritis  is  induced  by :  (^)  The  toxins  of  many  o  the  acute 
infectious  diseases  which  have  "been  referred  to ;  ((5)  the  metalhc  poisons, 
lead,  arsenic,  mercury,  or  phosphorus,  and  such  organic  poisons  as  alco- 
hol, ether,  carbon  bisulphid,  ergot,  anilin,  and  illuminating  gas;  (r) 
the  undetermined  intoxicant  of  beriberi;  (^)  cachectic  conditions  as 
in  tuberculosis,  cancer,  marasmus,  or  anemia;  and  (^)  overexertion  or 
prolonged  exposure  to  cold. 

Morbid  Anatomy.— The  lesions  may  be  interstitial  or  parenchyma- 
tous. In  the  former  the  inflammation  may  be  limited  to  the  perineural 
connective  tissue,  or  it  may  extend  into  the  nerve  and  induce  a  cellular 
infiltration  between  the  bundles  and  a  prohferation  of  the  nuclei  of  the 
neurilemma.  The  nerve-fibers  may  be  unaffected,  or  they  may  be  de- 
stroyed by  subsequent  sclerosis. 

In  the  parenchymatous  form  the  changes  are  like  those  in  a  nerve- 
fiber  which  has  been  cut  off"  from  its  neuron  cell.  The  axis-cylinder 
and  myalin  become  fragmented,  and  a  granular  fatty  degeneration  com- 
pletes their  destruction.  The  fat  is  then  absorbed,  leaving  the  neurilemma 
empty,  but  still  showing  proliferated  nuclei.  The  muscles  supplied  by 
the  affected  nerve  atrophy  from  loss  of  innervation,  but  a  new  fiber 
sometimes  grows  along  the  periphery  and  restores  the  communication. 
Symptoms.— 1.  Localized  Neuritis.— The  symptoms  are  generally  local. 
Heat,  redness,  and  swelling  of  the  skin  are  commonly  observed  over  the 
affected  nerve,  which  is  extremely  sensitive  to  pressure.  An  intense 
aching  or  lancinating  pain  is  felt  along  the  course  of  the  nerve  and 
the  parts  supphed  by  it.     Localized  sweating,  an  eruption  of  herpes, 


622  PRACTICE  OF  MEDICINE 

muscular  twitching,  joint  effusion,  numbness,  formication,  impairment 
of  tactile  sense,  and  particularly  a  progressive  loss  of  motion  are  com- 
monly developed.  Atrophy  of  the  paralyzed  muscles  and  contractures 
ensue;  the  skin,  especially  of  the  fingers,  becomes  glossy,  and  the  nails 
brittle  (trophic  disturbances).  The  neuritis  may  extend  upward  from 
the  peripheral  to  the  larger  nerve-trunks,  especially  in  traumatic  cases 
(ascending  or  migratory  neuritis). 

Diagnosis. — -The  pain  is  constant  and  intensified  by  pressure — not 
relieved  as  in  neuralgia.  The  condition  is  further  distinguished  by  pares- 
thesia and  a  reaction  of  degeneration.  The  persistence  of  the  reflexes 
and  absence  of  incoordination  excludes  the  peripheral  pains  arising  from 
disease  of  the  cord.  The  duration  of  the  disease  varies  from  a  few  days 
to  several  months.     Recovery  is  not  always  complete. 

2.  Multiple  Neuritis. — The  attack  begins  abruptly,  or  after  a  short 
period  of  muscular  weakness,  with  numbness  or  tingling.  The  symp- 
toms may  be  acute  or  subacute. 

(rt;)  Acute  Febrile  Multiple  Neuritis. — There  is  often  a  chill  and  rapid 
rise  of  temperature  to  104°  F.  (40°  C),  headache,  vomiting,  and  mus- 
cular pains,  rapidly  followed  by  paralysis  beginning  in  the  feet  or  arms. 
Hyperesthesia  and  pain  of  variable  severity  accompany  the  paralysis. 
When  the  pneumogastric  is  involved,  tachycardia  and  labored  breathing 
are  produced.  More  or  less  complete  recovery  is  possible,  after  weeks 
or  months,  but  the  disease  is  often  fatal. 

if)  Subacute  cases  are  marked  by  numbness  and  tingling,  cramp- 
ing pain,  and  great  tenderness,  with  less  rapid  paralysis  of  the  muscles. 
Fever  may  be  present  or  absent.  The  reflexes  are  more  or  less  com- 
pletely lost.  The  hyperesthesia  subsides  and  is  followed  by  localized 
anesthesia.  The  condition  generally  becomes  chronic,  the  paralysis  per- 
sisting in  the  form  of  wrist-drop  or  foot-drop,  especially  in  lead  and 
alcoholic  cases.  The  muscles  later  atrophy  and  become  soft,  and  con- 
tractures develop.  Slight  reaction  to  the  galvanic  current  without  re- 
action to  the  faradic  is  characteristic.  Trophic  and  vasomotor  disturb- 
ances are  common.  The  cranial  nerves,  particularly  the  optic,  are 
sometimes  involved  in  severe  cases.  In  the  alcoholic  form,  neuralgic 
pains,  sensory  disturbances,  delirium,  or  convulsions  often  occur  and 
may  pass  into  confusional  insanity.  The  sphincters  may  be  tempo- 
rarily paralyzed.  Recovery  is  quite  common,  j,even  in  the  worst  cases, 
the  symptoms  gradually  subsiding;  but  the  steppage  gait  usually  per- 
sists for  several  months.  In  walking,  the  foot  is  raised  and  swung  for- 
ward in  order  to  prevent  the  toes  from  striking  the  ground.  Recurrence 
is  not  uncommon  in  alcoholic  cases,  and  occasional  in  those  due  tO' 
lead. 

Diagnosis. — The  combination  of  wrist-drop  and  foot-drop,  or  the 
latter  condition  alone,  is  highly  characteristic  of  multiple  neuritis.  These 
symptoms,  in  the  absence  of  inco-ordination,  exclude  locomotor  ataxia. 
Diffuse  myelitis  is  more  febrile.  The  cutaneous  anesthesia  and  muscular 
atrophy  are  more  pronounced  and  more  rapid;  trophic  disturbances 
and  sphincter  paralysis  more  common,  and  a  girdle  pain  may  be  present. 
Acute  a sceiiding  paralysis  is  attended  with  less  atrophy  and  sensory  dis- 
turbance, and  the  electrical  reactions  persist. 

Treatment.— Tht  patient  should  be  given  complete  rest.    The  affected 


DISEASES  OF  THE  CRANIAL  NERVES  623 

limbs  should  be  bandaged  on  splints  in  such  a  manner  as  to  permit 
local  applications  of  chloroform  liniment,  poultices,  or  lead  and  laudanum 
lotion  to  relieve  the  pain.  In  alcoholic  cases  the  stimulant  should  be 
withdrawn  gradually,  as  a  rule.  Care  must  be  taken  to  prevent  the 
formation  of  bedsores.  Later,  massage  and  the  interrupted  galvanic 
current  are  of  great  benefit.  The  contractures  must  be  overcome  by 
passive  motion  and  extension.  Strychnin  and  small  doses  of  arsenic 
assist  in  the  restoration  of  the  muscles.  The  results  of  persistent  treat- 
ment are  sometimes  remarkable. 


NEUROMATA. 

The  tumors  which  affect  the  nerve-fibers  are  divided  into  two  groups, 
true  neuromata  and  false  neuromata.  The  former  are  composed  of 
nerve-fibers,  rarely  of  ganglionic  cells;  the  latter  of  fibrous,  gummatous,, 
malignant,  or  gUomatous  tissue.  They  may  result  from  injury  in  sur- 
gical operations,  from  diathetic  disease,  as  leprosy,  or  they  may  rarely 
be  hereditary.  Their  favorite  seats  are  in  the  skin,  the  subcutaneous 
tissue,  the  amputation  stump,  or  along  the  course  of  the  nerve.  Multi- 
ple fibroneuromata  of  the  skin  are  known  as  fibroma  mohisaim,  those 
growing  on  the  terminal  filaments  of  the  sensory  nerves  as  tiibercula 
dolorosa. 

The  symptoms,  in  addition  to  the  presence  of  small  nodules,  are  pain 
and  tenderness  reheved  by  pressure  on  the  proximal  side,  paresthesia, 
or  anesthesia.  Constant  twitching  is  sometimes  present.  In  some  cases 
subjective  symptoms  are  absent.  The  treatment  is  surgical.  Excision 
is  usually  followed  by  complete  relief,  except  in  the  amputation  neuro- 
mata, which  are  liable  to  recur. 

DISEASES  OF  THE  CRANIAL  NERVES. 

The  cranial  nerves  are  subject  to  both  functional  and  organic  disturb- 
ancesr  In  the  former  there  is  no  anatomical  alteration,  the  condition 
often  being  associated  with  hysteria,  neurasthenia,  or  other  neurotic 
affections;  there  may  be  a  reflex  irritation,  or  the  nerve  may  be  com- 
pressed by  inflammatory  exudates  or  tumors.  The  organic  lesions 
include  neuritis  and  degenerations,  which  may  be  situated  at  the  periph- 
eral termination,  along  the  tract,  or  in  the  cerebral  centers.  The 
central  lesion  may  be  syphilitic,  inflammatory,  hemorrhagic,  or  septic; 
it  may  be  due  to  meningitis  of  either  form,  caries,  or  fracture  of  ther 
skull-bones.  The  result  is  a  temporary  or  permanent  increase,  diminu- 
tion,  or  loss  of  function. 

I.  OLFACTORY  NERVE  AND  TRACT. 

The  first  nerve  may  be  affected  in  its  nasal  origin,  the  bulb,  tract, 
or  central  nuclei.  The  result  is  a  disturbance  of  the  sense  of  smell. 
The  chief  causes  of  peripheral  disturbances  are  acute  or  chronic  rhinitis- 
and  ozena;  the  causes  of  deeper-seated  disease  are  meningitis,  especially 
tubercular;  tumors  of  the  hippocampus;  caries  of  the  ethmoid,  or  abscess- 


624  PIL\CTICE  OF  MEDICINE 

in  the  frontal  lobe.  The  functional  disturbances  are  anosmia,  hyperos- 
mia,   or  parosmia. 

Anosmia  is  a  loss  of  the  sense  of  smell.  This  may  be  purely  func- 
tional as  in  hysteria;  it  is  temporary  in  acute  rhinitis  and  when  due 
to  polypi,  and  more  permanent  in  chronic  rhinitis  or  destructive  disease 
of  the  nerve-tract.  It  sometimes  results  from  blows  upon  the  head, 
arrest  of  nasal  secretion  in  paralysis  of  the  fifth  nerve,  and  rarely  from 
atrophy  in  locomotor  ataxia.  It  is  occasionally  due  to  congenital  lack 
of  development. 

Hyperosmia  is  an  abnormal  acuteness  of  the  sense  of  smell,  usually 
associated  with  hysteria  or  neurasthenia.  Parosmia  is  a  perverted 
sense  of  smell,  observed  in  the  same  class  of  patients  or  in  the  insane, 
and  sometimes  as  an  aura  in  epilepsy. 

Treatment. — The  treatment  of  these  conditions  is  directed  to  the  re- 
moval of  the  cause,  but,  even  when  this  can  be  accomplished,  the  result 
is  not  always  satisfactory. 

II.  OPTIC  NERVE   AND    TRACT. 

Disease  of  the  optic  nerve  and  tract  produces  visual  disturbance, 
partial  or  complete  blindness.  Retinitis  and  neuroretinitis  are  of  greatest 
importance  to  the  general  practitioner,  from,  the  fact  that  their  recog- 
nition is  often  a  valuable  factor  in  the  diagnosis  of  chronic  nephritis, 
especially  the  interstitial  form.  They  are  met  with  also  in  profound 
anemia,  leukemia,  purpura,  and  syphilis.  The  changes  in  the  retina  are, 
for  the  most  part,  hemorrhagic  or  sclerotic.  The  hemorrhages  are  found 
in  the  layer  of  nerve-fibers  and  often  follow  the  course  of  the  blood- 
vessels. The  retina  ma}^  be  much  swollen  and  the  disk  obscured.  White 
opacities  are  commonly  seen,  which  are  due  to  fatty  degeneration  of  the 
retina,  extravasation  of  leucocytes,   or  fibrous  induration. 

Optic  neuritis,  papillitis,  or  choked  disk,  is  also  encountered  in  chronic 
nephritis,  even  more  frequently  than  neuroretinitis,  as  a  result  of  pres- 
sure by  a  tumor  within  the  cranium,  or  in  connection  with  simple  or 
tubercular  meningitis.  The  condition  is  recognized  from  the  peculiar  ap- 
pearance of  the  disk.  The  edges  are  opaque  and  striated  and  the  center 
congested,  both  appearances  increasing  as  the  disease  progresses.  The 
depression  disappears  with  the  swelling,  and  hemorrhages  often  take 
place.  The  congestion  may  subside  in  the  less  severe  cases,  but  atrophy 
of  the  nerve  often  ensues. 

Atrophy  of  the  optic  nerve  is  generally  due  to  pressure  neuritis  asso- 
ciated with  tumors,  but  it  mav  be  a  congenital  condition.  It  some- 
times occurs  in  diabetes,  locomotor  ataxia,  acute  infectious  diseases, 
or  other  toxic  conditions.  The  field  of  vision  is  reduced,  the  color  sense 
impaired,  and  total  blindness  may  ensue. 

Functional  disturbances  of  vision  arise  from  many  causes  :  («;)  Par- 
tial or  complete  blindness  (amaurosis)  sometimes  occurs  in  hysteria 
and  other  neurotic  states,  or  as  a  result  of  violent  emotional  excitement. 
(<5)  Toxic  amaurosis,  usually  of  a  few  days'  duration,  sometimes  fol- 
lows poisoning  by  lead,  alcohol,  quinin,  or  tobacco,  (r)  Amblyopia 
(dimness  of  vision)  is  a  more  common  result  of  excessive  use  of  tobacco. 
It  is  progressive,  and,  if  the  habit  is  persisted  in,   frequently  leads  to 


DISEASES  OF  THE  CRANIAL  NERVES  625 

organic  change  with  atrophy  of  the  disk.  A  central  dark  spot  (scotoma) 
to  tests  with  red  and  green  is  ahvays  found.  (^)  Night-thndness  (nyc- 
talopia), in  which  objects  visible  by  day  cannot  be  seen  in  a  dim  light, 
and  the  opposite  condition,  hemeralopia,  in  which  objects  cannot  be 
distinctly  seen  in  a  strong  light,  are  among  the  curiosities  of  visual 
disturbance.  (^)  Retinal  hyperesthesia  is  a  rare  condition  usually 
seen  in  hysterical  women.  (/")  Photophobia  is  a  common  condition  in 
the  initial  stages  of  the  acute  infections  and  may  be  met  with  in  neu- 
rotic states.  (^)  Hemianopia,  in  which  one-half  of  the  visual  field  is 
obscured,  may  be  functional,  associated  with  hysteria  or  migraine;  but 
in  some  cases  it  is  organic  and  due  to  lesions  in  the  optic  chiasm,  or 
anywhere  between  this  and  the  cortical  center.  It  is  sometimes  due  to 
the  pressure  of  a  tumor  in  the  cerebral  cortex.  The  outer  half  of  both 
fields  is  usually  affected  (temporal  hemianopia)  in  lesions  of  the  cen- 
tral portion  of  both  chiasms;  the  inner  portion  (nasal  hemianopia) 
is  affected  in  lesions  of  the  lateral  region  of  both  chiasms.  Lateral 
hemianopia  is  produced  by  lesions  between  the  chiasm  and  lateral  genic- 
ulate body,  lesions  of  the  central  fibers  of  the  nerve  between  the  genic- 
ulate bodies  and  cortex,  and  by  lesions  of  the  cuneus.  Lesions  of  the 
angular  gj^rus  and  injuries  of  the  brain  in  its  vicinity  may  produce 
hemianopia,  crossed  ambtyopia,  or  mind-blindness,  in  which  things  are 
seen,   but  cannot  be  named. 

Treatment  is  beneficial  only  when  the  cause  can  be  removed,  as  in 
tobacco,  amblyopia,  some  cases  of  injury  or  tumor,  and  in  cases  due  to 
syphilis,  malaria,  anemia,  or  nephritis. 


III.   OCULOMOTOR  NERVE. 

Lesions  of  this  nerve  may  be  situated  in  the  nucleus  of  origin,  or 
along  the  course  of  the  nerve.  Either  paralysis  or  spasm  is  produced. 
In  character  the  lesion  may  be  a  neuritis,  irritation  from  the  pressure 
of  a  gumma  or  other  tumor,  or  meningitis.  The  central  lesions  are  usu- 
ally associated  with  those  of  other  ocular  nerves. 

Paralysis  due  to  a  central  lesion  is  generally  associated  with  paralysis 
of  other  muscles,  producing  general  ophthalmoplegia.  \Mien  not  asso-. 
ciated,  there  is  generally  a  neuritis  or  other  lesion  in  the  course  of  the 
nerve,  as  sometimes  occurs  in  diphtheria  or  locomotor  ataxia,  or  in 
meningitis,  gumma,  or  aneurism.  Complete  paralysis  of  this  nerve 
includes  all  the  muscles  of  the  eye,  except  the  superior  oblique  and 
external  rectus,  producing  ptosis,  divergent  strabismus  with  double 
vision  (diplopia).  Partial  paralyses  involve  only  the  levator  palpebrae 
and  superior  rectus,  the  ciliary  muscles  (cycloplegia),  or  the  iris  (irido- 
plegia).  Iridoplegia  may  be  manifested  in  three  ways,  (ji)  The  pupil 
fails  to  contract  with  accommodation  for  a  near  object.  (Ji)  There  is 
loss  of  the  iris-reflex.  If  a  bright  light  is  flashed  into  the  eye  while 
the  individual  is  looking  at  a  distant,  dark  object,  the  iris  fails  to  con- 
tract. This  loss  of  reflex  without  loss  of  accommodation-contraction 
is  known  as  the  Argyll  Robertson  pupil,  an  important  element  in  the 
diagnosis  of  locomotor  ataxia.  (^)  Loss  of  the  skin-reflex,  in  which 
the  pupil  fails  to  dilate  when  the  skin  of  the  neck  is  pinched. 
40 


626  PRACTICE  OF  MEDICINE 

A  periodically  recurrent  complete  oculomotor  paralysis  is  sometimes 
observed.  Anisocoria,  or  inequality  of  the  pupils,  is  sometimes  a  feature 
of  tabes  or  paresis,  but  it  may  occur  in  healthy  persons. 

Spasm  of  the  muscles  supplied  by  the  third  nerve,  particularly  of  the 
internal  rectus  and  levator  palpebrse,  is  sometimes  met  with  in  men- 
ingitis and  hysteria.  A  rhythmical  involuntary  clonic  spasm  of  the  eye, 
known  as  nystagmus,  is  not  infrequently  seen  in  meningitis  and  other 
brain-diseases  in  children.  It  is  sometimes  met  with  in  adults,  par- 
ticularly in  albinos,  independently  of  nerve-disease. 


IV.  FOURTH  NERVE. 

This  nerve  is  subject  to  lesions  of  the  same  character  as  the  preced- 
ing. Paralysis  impairs  the  downward  motion  of  the  eye,  and  is  mani- 
fested by  strabismus  and  double  vision  when  the  patient  looks  down- 
ward. 

V.   FIFTH  OR  TRIGEMINUS  NERVE. 

Neuritis  is  not  frequent  in  this  nerve.  Its  intracranial  lesions  are 
more  commonly  due  to  meningitis,  sclerosis,  hemorrhage,  or  tumor  of 
the  bones.  It  is  sometimes  due  to  injury  by  caries  or  fracture  of  the 
skull.  Its  extracranial  portion  may  be  involved  in  tumors  or  injury. 
The  results  are  paralysis,  and  sensory  or  trophic  disturbances. 

(<?)  Motor  Portion.— The  paralysis  affects  the  temporal  and  masse- 
ter  muscles,  interfering  with  mastication.  The  jaw  deviates  toward 
the  affected  side  when  opened,  owing  to  weakness  of  the  pterygoid 
muscle. 

Spasm  of  the  muscles  of  mastication,  trismus,  or  lock-jaw,  may  be 
tonic  or  clonic,  and  a  common  symptom  in  general  convulsions. 
It  sometimes  follows  reflex-irritation  in  the  mouth  or  teeth,  caries  of 
the  jaw,  or  exposure  to  cold.  It  also  follows  organic  disease  near  the 
motor  nucleus  of  the  nerve.  The  tonic  form  of  the  spasm  is  a  distin- 
guishing feature  of  tetanus,  is  occasionally  seen  in  tetany,  and  may  com- 
plicate hysteria.  Clonic  spasm,  producing  chattering  of  the  teeth,  is 
usually  seen  in  hysteria  or  chorea,  but  occasionally  as  an  independent 
affection. 

{P)  Sensory  Portion. — Lesions  of  this  portion  produce  tingling  or 
anesthesia  of  the  parts  supplied,  the  half  of  the  face,  side  of  the  head, 
and  the  mucous  membranes  of  the  lips,  tongue,  hard  and  soft  palate, 
nose,  and  conjunctivae.  Arrest  of  the  nasal  secretion  affects  the  sense 
of  smell;  the  sense  of  taste  may  also  be  modified,  and  trophic  changes 
not  infrequently  ensue  in  the  affected  parts.  Opacities  and  ulcers  of 
the  cornea  are  common,  persistent  and  painful  eruptions  of  herpes  often 
appear  on  the  face,  the  teeth  become  loose  and  may  drop  out.  The 
supraorbital  reflex  is  usually  absent. 

Gustatory  Disturbances.— The  sense  of  taste  is  generally,  though  not 
always,  lost  in  the  anterior  two-thirds  of  the  tongue  when  this  nerve  is 
paralyzed. 

Treatment  consists  in  removing  the  cause  when  this  is  possible.   Mor 


DISEASES  OF  THE  CIL\XIAL  NERVES  627 

phin  may  be  required  for  the  pain,  and  local  applications  are  of  benefit, 
especially  when  the  condition  is  due  to  neuritis  of  the  superficial  portion 
of  the  nerve.  Faradization  and  massage  of  the  affected  muscles  are 
beneficial.    Syphilitic  cases  require  specific  treatment. 


VI.   SIXTH  NERVE   (NERVUS  ABDUCENS). 

This  nerve  is  subject  to  the  same  affections  as  the  other  motor  nerves 
of  the  eye,  especially  in  connection  with  syphilis,  meningitis,  and  tabes. 
The  result  is  paralysis  of  the  external  rectus  muscle,  producing  internal 
strabismus,  with  inability  to  rotate  the  eye  outward,  and  diplopia 
when  the  patient  looks  toward  the  affected  side.  When  the  lesion  is  in 
the  nucleus,  the  opposite  eye  cannot  be  turned  inward,  and  both  eyes 
deviate  from  the  side  of  the  lesion. 

Ophthalmoplegia. — This  term  signifies  a  chronic,  progressive  paraly- 
sis of  the  ocular  muscles.  The  condition  is  a  rare  one,  occurring  in  two 
forms,  affecting  the  external  or  the  internal  muscles  of  the  eyeball.  Its 
usual  cause  is  nuclear  degeneration,  but  it  sometimes  arises  from  the 
pressure  of  a  tumor  or  the  exudate  in  basilar  meningitis.  Optic-nerve 
atrophy  and  cerebral  symptoms  may  be  associated  with  it. 

Treatment  of  Ocu/ar  Paralyses. — Recovery  sometimes  occurs  spontane- 
ously after  cessation  of  the  cause  or  when  this  can  be  removed.  The 
most  successful  treatment,  as  in  all  nervous  diseases,  is  obtained  in 
syphilitic  cases.  Conditions  associated  with  locomotor  ataxia  resist 
treatment.  When  the  onset  is  acute,  local  hot  applications  are  some- 
times beneficial.  Tonics,  especially  arsenic  and  strychnin,  are  some- 
times useful. 

VII.   FACIAL  NERVE. 

Paralysis  (Facial  Paralysis,  Bell's  Paralysis).— Facial  paralysis  may 
arise  from  :  (^)  Lesions  of  the  cortex,  including  fibers  in  the  corona 
radiata  or  internal  capsule,  in  connection  with  cerebral  hemorrhage 
or  softening,  tumors,  abscesses,  or  chronic  inflammation ;  (^)  the  effect 
of  the  toxins  of  infectious  diseases,  particularly  of  diphtheria;  (r)  lesions 
in  the  nerve,  most  frequently  caused  by  exposure  of  the  face  to  an 
intensely  cold  wind;  injury  at  its  point  of  emergence  by  meningitis, 
gummata  and  other  tumors,  or  fracture  of  the  base,  and  lesions  in  the 
Fallopian  canal  from  suppuration  of  the  middle  ear  or  caries.  The  nerve 
is  sometimes  severed  in  surgical  operations  or  compressed  by  the  obstet- 
ric forceps  in  delivery,  causing,  as  a  rule,  only  temporary  paralysis. 

Symptoms. — Facial  paralysis  is  more  frequent  in  children  or  young 
adults,  rarely  congenital.  In  peripheral  cases,  especially  after  exposure 
to  cold,  the  onset  is  sudden,  and  all  the  branches  of  the  nerve  are  in- 
volved. The  patient  experiences  a  sense  of  numbness  or  tingling  on  the 
affected  side  and  is  unable  to  produce  voluntary  movement  of  it.  The 
eyelids  remain  open,  and  the  lips  are  drawn  slightly  toward  the  other 
side.  The  tears  escape  from  the  eyes  and  the  saliva  from  the  mouth. 
Difficulty  is  experienced  in  drinking,  mastication,  pronouncing  the  labials, 
and  in  expectorating.    The  patient  cannot  purse  the  mouth  as  in  whis- 


62  8  PRACTICE  OF  MEDICINE 

tling.  The  reflex  and  normal  electrical  reaction  are  lost.  The  skin  is 
smooth  and  the  forehead  cannot  be  wrinkled.  The  skin  may  be  edema- 
tous, and  an  eruption  of  herpes  sometimes  develops  at  the  angles  of  the 
eyes  and  on  the  lips.  The  paralysis  is  best  demonstrated  by  causing 
the  patient  to  laugh.  Absence  of  the  supraorbital  reflex  serves  to  dif- 
ferentiate a  peripheral  facial  paralysis  from  one  of  central  origin. 

Facial  diplegia,  or  paralysis  of  both  sides,  is  a  rare  form  beautifully 
illustrated  by  Thompson,  usually  due  to  lesions  at  the  base  of  the 
brain,  in  the  pons,  or  to  simultaneous  lesions  in  both  nerves,  as  in  diph- 
theria or  middle-ear  disease. 

When  facial  paralysis  is  associated  with  hemiplegia,  the  reflexes  per- 
sist, and  cerebral  symptoms  are  usually  present.  The  paralysis  is  most 
marked  in  the  lower  portion  of  the  face.  WTien  the  lesion  is  in  the 
Fallopian  canal,  there  are  deviation  of  the  uvula,  impairment  of  the  sense 
of  taste  (probably  due  to  injury  to  the  nerve  of  Wrisberg),  and  evidence 
of  middle-ear  disease.  Paralysis  of  central  origin  is  always  accompa- 
nied by  involvement  of  other  cranial  nerves.  Paralysis  of  the  stapedius 
muscle  is  indicated  by  increased  sensitiveness  to  musical  sounds,  often 
amounting  to  pain. 

Prognosis. — The  prognosis  is  good,  except  in  cases  due  to  destruc- 
tion of  the  nerve  by  injury  or  suppuration.  The  recovery  is  some- 
times slow  and  not  always  complete.  Contractures  often  develop  with 
the  restoration  of  motion. 

Treatment. — Cases  due  to  cold  are  often  benefited  by  the  application 
of  poultices  or  hot  fomentations.  Stronger  counter-irritation  may  be 
made  with  blisters  or  the  thermocautery  over  the  mastoid.  If  due  to 
middle-ear  disease,  this  must  be  given  drainage  and  proper  treatment. 
When  syphilis  is  suspected,  potassium  iodid  and  mercury  should  be  pre- 
scribed. Calcium  sulphid  is  indicated  in  all  cases  associated  with  sup- 
puration, unless  syphilitic.  Later,  faradization  and  massage  of  the  mus- 
cles are  of  great  service. 

Spasm  may  affect  any  or  all  of  the  muscles  innervated  by  the  facial 
nerve.  It  may  be  primary  or  secondary,  sometimes,  perhaps,  reflex,  and 
may  afiect  one  or  both  sides.  When  organic,  the  lesion  is  generally 
central.  Various  muscles  or  groups  of  muscles  are  intermittently  thrown 
into  contraction,  under  excitement,  fatigue,  or  emotion.  The  orbicularis 
and  the  muscles  in  its  vicinity  are  most  commonly  aff"ected.  Closely 
allied  to  this  is  the  habit  spasm  or  convulsive  tic  (tic  convulsif)  of 
children,  sometimes  persisting  through  later  life. 

The  treatment  consists  first  in  the  removal  of  any  recognized  irrita- 
tion. A  painful  spot  sometimes  exists  and  should  be  made  the  seat 
for  the  application  of  blisters,  the  thermocautery,  or  methyl-chlorid 
spray. 

VIII.   AUDITORY  NERVE. 

Central  lesions  are  rare.  The  cochlear  branch  is  more  frequently 
affected  in  its  course  than  the  vestibular.  Either  branch  may,  however, 
be  the  seat  of  inflammation  or  neuritis,  the  latter  especially  in  diph- 
theria and  cerebrospinal  meningitis,  or  it  may  be  involved  in  tumors, 
hemorrhage,  or  fracture  at  the  base.  A  primary  degeneration  some- 
times occurs  in  locomotor  ataxia. 


DISEASES  OF  THE  CRANIAL  NERVES  629 

The  cochlear  p07-tion  may  be  afifected  in  its  cortical  center,  producing 
word-deafness,  in  which  words  are  not  comprehended,  although  heard; 
or  the  central  auditory  path  may  be  affected,  producing  deafness.  In 
most  cases  affecting  the  hearing  the  lesion  is  an  extension  of  inflamma- 
tion from  the  middle  ear.  Hyperesthesia  (hyperaqusis),  or  abnormally 
acute  hearing,  sometimes  results,  but  partial  or  complete  deafness  is  more 
common.  The  nerve  is  often  affected  also  in  the  acute  infectious  dis- 
eases, or  by  the  loud  vibration  in  machine  shops.  Functional  disturb- 
ances occur  in  hysteria  and  other  nervous  conditions.  Hallucinations 
of  hearing  frequently  arise  in  insanity  and  paresis. 

Tinnitus  is  the  term  employed  to  embrace  a  large  group  of  abnor- 
mal subjective  sound-perceptions,  as  ringing,  crackling,  buzzing,  and 
roaring.  These  may  result  from  disease  of  the  ear,  obstruction  of  the 
Eustachian  tubes,  the  pressure  of  wax  on  the  tympanum,  injury,  or  they 
may  be  associated  with  anemia,  cardiac  hypertrophy,  or  increased  arte- 
rial tension  due  to  other  causes.  Tinnitus  sometimes  occurs  as  an  aura 
in  epilepsy. 

The  vestibular  portion '  is  rarely  affected.  .  The  distinguishing  symp- 
toms are  vertigo,  nystagmus,  and  a  disturbance  of  the  equilibrium  of 
the  head,  due  to  loss  of  co-ordination. 

Auditory  vertigo,  or  Meniere's  disease  (labyrinthine  vertigo),  is  a  pe- 
culiar form  of  vertigo,  associated  with  noises  in  the  ears,  vomiting, 
rarely  with  loss  of  consciousness,  and  followed  by  gradual  loss  of  hear- 
ing in  some  cases.  It  has  been  attributed  to  inflammatory  disease 
or  hemorrhage  of  the  labyrinth,  and  to  organic  changes  in  the  audi- 
tory nerve,  but  little  is  known  of  its  pathology.  The  symptoms  occur 
periodically  at  intervals  varying  from  a  day  to  several  months.  The 
attack  comes  on  suddenly,  sometimes  accompanied  with  other  nervous 
disturbances. 

Treatment. — In  hysterical  cases  the  bromids  are  beneficial;  in  neuras- 
thenics, rest  and  tonics,  with  light  exercise ;  in  increased  arterial  tension, 
nitroglycerin;  in  syphilitics,  specific  treatment.  Quinin  and  the  salicy- 
lates improve  some  cases.  The  correction  of  errors  of  refraction  some- 
times relieves  a  vertigo  attributed  to  auditory  disease.  The  treatment 
of  Meniere's  disease  is  very  unsatisfactory. 


IX.  GLOSSOPHARYNGEAL  NERVE. 

Primary  diseases  are  rare.  The  nucleus  is  probably  involved  in  cases 
of  bulbar  paralysis,  and  the  trunk  may  be  compressed  by  tumors  or  the 
exudate  in  meningitis.  The  sense  of  taste  may  be  impaired  in  the  pos- 
terior part  of  the  tongue  and  palate,  but  it  is  not  lost.  The  upper 
part  of  the  pharynx  becomes  anesthetic  and  the  middle  portion  para- 
lyzed, rendering  deglutition  difficult. 


X.   PNEUMOGASTRIC  (VAGUS)  NERVE. 

The  nucleus,  the  intracranial  or  extracranial  branches  may  be  affected 
in  the  same  manner  as  the  other  cranial  nerves.  The  results  are  exceed- 
ingly various,  owing  to  the  wide  distribution  of  the  branches. 


630  PRACTICE  OF  MEDICINE 

Pharyngeal  Branches. — Paralysis  may  follow  diphtheria  or  accom- 
pany bulbar  paralysis,  causing-  difficulty  of  deglutition,  particularly  when 
only  one  side  is  involved.  The  food  may  pass  into  the  larynx,  or  it 
may  be  regurgitated  into  the  posterior  nares.  Spasm  occurs  also  in 
hysteria  or  under  emotional  disturbance  (globus  hystericus),  and  in 
both  true  and  false  hydrophobia. 

Laryngeal  Branches. — Affections  of  these  branches  produce  paralysis 
of  the  vocal  cords  or  of  the  adductor  or  abductor  muscles,  with  stridu- 
lous  respiration,  cough,  and  hoarseness  or  huskiness  of  the  voice,  or  com- 
plete aphonia  and  dyspnea.  These  may  result  from  diphtheritic  paraly- 
sis, pressure  of  a  thoracic  aneurism,  mediastinal  tumor,  or  goiter  upon 
the  recurrent  laryngeal  branch.  Functional  disturbances  are  common 
in  hysteria,  especially  adductor  paralysis,  with  complete  aphonia.  Spasm 
occurs  in  laryngismus  stridulus,  in  the  crises  of  locomotor  ataxia,  and 
in  hysteria. 

Pulmonary  Branches. — We  have  no  positive  knowledge  regarding  the 
affections  of  these  branches.  That  bronchial  asthma  is  due  to  central 
lesions  of  this  nerve  in  some  cases  is  an  old  theory,  lacking  support. 
Disturbance  of  respiration  of  vagus  origin  is  probably  always  accom- 
panied with  cardiac  disturbance. 

Cardiac  Branches. — Motor,  sensory,  and  trophic  disturbances  of  the 
heart  are  believed  to  result  from  disease  or  irritation  of  these  fibers. 
Bradycardia  and  tachycardia  are  examples  of  motor  disturbances  of 
this  character.  The  nerve  may  also  be  involved  in  a  multiple  neuritis, 
and  it  is  commonly  affected  by  the  toxins  of  the  infectious  diseases. 
The  respiration  is  generally  increased  in  rate  when  the  action  of  the 
heart  is  accelerated.  The  sensations  of  fluttering  and  faintness  asso- 
ciated with  irregularity  of  rhythm  are  transmitted  to  the  brain,  it  is 
believed,  by  the  pneumogastric  nerve.  (See  Cardiac  Neuroses.)  The  more 
profound  lesions  of  the  cardiac  branches  produce  fatty  degeneration  of 
the  myocardium. 

Esophageal  and  Gastric  Branches.— Paralysis  or  spasm  of  the  esoph- 
agus and  various  disturbances  of  gastric  sensation,  as  pain,  hunger, 
satiety,  and  the  motor  disturbances  described  under  Neuroses  of  the 
Stomach,  are  attributable  to  changes  in  these  branches. 

XI.  SPINAL  ACCESSORY  NERVE. 

Paralysis  may  result  from  involvement  of  the  nuclei  or  of  the  cord. 
The  nuclei  of  the  internal  portion  are  involved  especially  in  bulbar 
paralysis,  those  of  the  external  portion  in  progressive  muscular  atrophy. 
Paralysis  may  result  also  from  diseases  of  the  spinal  cord  or  meninges 
affecting  the  cervical  portion,  caries  of  the  vertebrae,  and  injury.  The 
manifestations  are  atrophy  of  the  sternomastoid  muscle  of  the  affected 
side,  with  diminished  power  of  rotating  the  head  toward  the  opposite  side, 
and  partial  paralysis  of  the  trapesius,  interfering  with  the  lifting  of  the 
arm  and  the  internal  rotation  of  the  angle  of  the  scapula.  The  shoulder 
droops,  and  the  supraclavicular  depression  is  increased.  Bilateral  paraly- 
sis of  the  sternomastoid  in  progressive  muscular  atrophy  permits  the 
head  to  fall  backward.  When  the  trapezii  are  affected,  however,  it  falls 
forward. 


DISEASES  OF  THE  CRANIAL  NERVES  631 

Treatment. — Cases  due  to  central  lesion  are  seldom  benefited  by  treat- 
ment. Disturbance  due  to  pressure  is  sometimes  relieved,  especially  if  due 
to  syphilitic  formations. 

Spasm  (wry-neck,  torticollis)  may  be  congenital  or  acquired.  The 
former  is  a  stationary,  fixed  contraction;  the  latter  may  be  tonic  or 
clonic. 

Congenital  wry-neck  is  due  to  lack  of  muscular  development  or  to 
injury  during  delivery,  and  is  probably  never  of  nervous  origin.  It 
affects  the  right  side,  as  a  rule,  and  often  passes  unnoticed  for  several 
years  after  birth.  It  is  usually  associated  with  facial  asymmetry.  The 
mastoid  muscle  is  much  shortened  and  hard.  The  trapesius  is  affected 
in  rare  instances. 

Acquired  torticollis  may  also  arise  from  other  than  nervous  influences, 
as  from  rheumatism  (myositis),  adenitis,  caries,  or  neoplasms.  The 
true  spasmodic  form  occurs  without  recognizable  lesions  and  in  asso- 
ciation with  vascular  and  trophic  disturbances. 

A  nodding  spasm  of  the  muscles  of  this  group  is  occasionally  seen 
in  children  and  hysterical  women. 

Symptoms.— The  head  is  rotated  upward  and  away  from  the  side 
of  the  lesion.  The  spasm,  at  first  clonic,  may  become  tonic.  The  facial 
nerve  or  the  brachial  plexus  may  also  be  involved,  producing  a  combined 
spasm  of  the  muscles  supplied.  In  clonic  cases  the  muscles  become 
painful  and  sensitive,  and  in  tonic, cases  much  suffering  is  sometimes 
induced  by  the  strong  contraction.  The  muscles  involved  become  large 
and  firm. 

Prognosis. — Recovery  is  possible,  but  it  is  unusual.  The  disease  be- 
comes chronic,  or,  if  relieved,  it  recurs. 

Treatment.— This  is  often  unsatisfactory.  The  bromids,  hyoscyamus, 
and  the  galvanic  current  have  yielded  good  results  in  some  cases.  Re- 
currence is  the  rule.    Surgical  measures  have  been  employed. 

XII.  HYPOGLOSSAL  NERVE. 

This  nerve  also  is  subject  to  nuclear  lesions,  usually  bilateral,  due 
to  degeneration,  especially  in  bulbar  paralysis  or  locomotor  ataxia; 
injury,  or  pressure  by  tumors;  meningitis,  gout,  or  lead-intoxication. 
In  its  course  it  may  be  affected  by  tumors,  disease  of  the  skull  or  cica- 
trices. Cortical  lesions  of  the  nerve  are  usually  associated  with  hemi- 
plegia. In  either  form,  the  tongue  is  affected,  and  speech  is  interfered 
with.  In  nuclear  lesions  the  tongue  undergoes  atrophy,  but  in  cortical 
disease  this  is  unusual  and  the  electrical  reactions  are  retained. 

Symptoms.— Fara/ysts.— This  is  usually  unilateral,  and  the  tongue, 
when  protruded,  deviates  toward  the  affected  side,  except  when  the  lesion 
is  within  the  medulla,  when  it  deviates  toward  the  sound  side.  In  pe- 
ripheral lesions  it  is  protruded  toward  the  affected  side.  Speech  is  not 
greatly  interfered  with.  Paralysis  of  the  larynx  and  of  the  palate  mus- 
cles of  the  affected  side  is  associated  with  it.  When  a  complete  bilateral 
paralysis  occurs,  the  tongue  lies  motionless  on  the  floor  of  the  mouth. 
Speech,  mastication,  and  deglutition  are  difficult,  but  the  senses  of  taste 
and  touch  are  not  interfered  with.  The  tongue  atrophies,  the  electrical 
reaction  is  lost,  and  a  fibrillary  tremor  develops. 


632  PRACTICE  OF  MEDICINE 

Spasm  may  affect  one  or  both  sides  of  the  tongue,  but  it  is  rare, 
and,  as  a  rule,  associated  with  epilepsy,  chorea,  hysteria,  or  facial  spasm. 
Stuttering  is  sometimes  due  to  it.  Cases  have  been  observed  in  which 
a  paroxysmal  clonic  spasm  causes  the  tongue  to  be  rapidly  thrust  out 
and  in,   even  during  sleep.     Recovery  is  usual  in  all  forms. 

DISEASES  OF  THE  SPINAL  NERVES. 

CERVICAL   PLEXUS. 

This  plexus  and  its  branches  may  be  involved  in  neuralgia,  paralysis, 
or  spasm.  Occipitocervical  neuralgia  results  from  exposure  to  cold,  injury, 
especially  that  from  carrying  burdens  on  the  neck,  caries  of  the  vertebrae, 
or  tumors.  The  pain  is  situated  in  the  back  of  the  head,  the  neck  and 
ear.  Tender  points  are  found  between  the  mastoid  and  spine,  above  the 
parietal  eminence,  and  between  the  sternomastoid  and  trapesius. 

Phrenic  Nerve  Disease. — Paralysis  may  be  due  to  a  lesion  in  its  origin 
or  course,  rarely  to  neuritis  after  diphtheria  or  lead-poisoning.  It 
sometimes  follows  ascending  myelitis.  Sudden  paralysis  causes  dyspnea 
and  cyanosis;  less  rapidly  developed,  it  is  characterized  by  dyspnea  on 
exertion,  inability  to  draw  a  full  breath  and  thoracic  breathing  due 
to  paralysis  of  one  or  both  halves  of  the  diaphragm.  The  abdominal 
wall  protrudes  in  expiration  instead  of  with  inspiration.  The  chief 
dangers  lie  in  the  development  of  bronchitis,  hypostatic  congestion,  or 
edema  of  the  lungs.  The  diagnosis  is  often  difficult,  and  the  condition 
may  be  confounded  with  the  fixation  of  the  diaphragm  due  to  inflam- 
mation in  its  vicinity,   as  in  pleurisy,  peritonitis,  or  abscess. 

Treatment  is  not  successful,  as  a  rule,  except  when  the  condition  is 
due  to  neuritis. 

Spasm. — The  best  examples  of  this  are  seen  in  torticollis,  already  de- 
scribed, and  in  hiccough. 

Hiccough  is  caused  by  a  sudden,  intermittent  contraction  of  the  di- 
aphragm, with  sudden  closure  of  the  glottis.  The  afferent  impression 
may  be  peripheral  or  central ;  the  efferent  impulse  is  through  the  phrenic 
nerve,  accompanied,  however,  with  an  impulse  through  the  recurrent 
laryngeal  branch  of  the  vagus.  With  reference  to  cause,  the  condition 
may  be  :  («;)  Irritative,  as  when  the  spasm  is  excited  by  swallowing 
hot  or  dry  food,  disease  of  the  lower  extremity  of  the  esophagus,  gastric 
or  intestinal  indigestion ;  (F)  inflammatory,  occurring  in  gastritis,  peri- 
tonitis, appendicitis,  hernia,  internal  strangulation,  or  typhoid  fever; 
(jT)  specific,  in  which  the  condition  accompanies  cancer  of  the  stom- 
ach, mediastinal  tumor,  gout,  diabetes,  nephritis,  or  other  constitutional 
disease.  These  cases  are  the  most  persistent;  (<^)  neurotic,  occurring 
in  hysteria,  cerebral  tumor,  epilepsy,  emotional  disturbance,  shock,  or 
as  a  reflex  from  a  peripheral  irritation.  The  attacks  vary  in  duration 
from  a  few  hours  to  several  weeks  or  months. 

The  prognosis  is  unfavorable  only  in  cases  complicating  the  more 
serious  organic  diseases. 

Treatment.— In  the  less  severe  cases  many  of  the  popular  remedies 
are  effective,  as  a  drink  of  cold  water,  swallowing  ice,  salt,  vinegar, 
lemon-juice  or  strong  brandy,  a  sudden  fright,  or  the  induction  of  sneez- 
ing.    Prolonged,  firm  pressure   in   the   epigastrium,    a   tight   bandage 


DISEASES  OF  THE  SPINAL  NERVES  635 

around  the  lower  thorax,  massage  of  the  abdomen,  an  emetic  or  lavage 
of  the  stomach,  will  relieve  some  of  the  more  severe  cases.  The  cold 
pack  is  often  promptly  curative.  Of  internal  remedies  there  are  many, 
'but  they  must  be  tried  in  succession  in  the  worst  cases  and  none  is 
infallible.  Of  these  the  best  are  :  Cocain,  gr.  1-6  (o.oi);  spirit  of  chlor- 
oform, 3  ss  (1.8)  ;  codein,  gr.  ss  (o.o3),asafetida,  and  the  bromids.  Mor- 
phin  may  be  employed  hypodermically  in  the  worst  cases,  but  its  effect 
is  usually  only  transitory.  Pilocarpin,  nitroglycerin,  apomorphin,  and 
inhalations  of  chloroform  or  amyl  nitrit  have  been  curative  in  some  cases. 
Pressure  over  the  phrenic  nerve  and  galvanism  have  been  recommended, 
but  it  is  not  probable  that  the  electric  current  can  be  made  to  reach  the 
nerve. 

BRACHIAL   PLEXUS. 

The  nerve-trunks,  before  entering  the  plexus,  may  be  compressed  in 
the  supraclavicular  region  by  tumors,  enlarged  glands  or  aneurism,  or 
injured  by  blows  or  inflammation.  Neuritis  is  rare,  but  it  may  occur 
as  an  ascending  inflammation  from  the  peripheral  branches.  The  most 
common  lesion  of  the  plexus  is  injury  produced  by  subcoracoid  dis- 
location of  the  humerus.  Blows  upon  the  shoulder  and  the  use  of  an 
improper  crutch  are  occasional  causes  of  complete  paralysis  of  the  arm. 
The  plexus  of  the  infant  may  be  injured  by  traction  with  the  finger 
or  hook  in  the  axilla  during  delivery,  that  of  the  adult  by  methods 
for  the  reduction .  of  shoulder  dislocation.  The  result  in  all  cases  is 
paralysis  of  the  muscles  supplied  by  the  branches  of  the  plexus.  The 
loss  of  power  may  be  preceded  by  numbness,  pain,  or  formication.  The 
paralysis  may  develop  after  reduction  of  the  dislocation  and  may  per- 
sist notwithstanding  the  removal  of  the  cause.  The  entire  plexus  or  only 
one  or  more  of  its  branches  may  be  affected.  The  results  are  different 
with  the  affection  of  each  branch.  In  lesions  of  the  upper  and  middle 
portions  of  the  plexus,  the  upper  arm  is  paralyzed,  and  the  ability  to 
flex  the  arm  is  lost.  Lesions  of  the  last  two  cervical  and  first  dorsal 
paralyze  the  hand  and  abolish  extension  of  the  forearm. 

Lesions  of  the  Nerves  of  the  Arm.— (^)  TJie  Long  Thoracic— V ax aly- 
sis  of  this  nerve  affects  the  serratus  magnus.  The  angle  and  posterior 
border  of  the  scapula  stand  out  from  the  chest,  especially  when  the 
arm  is  drawn  forward  and  the  movement  of  the  shoulder  is  restricted. 
Neuralgia  is  often  present  from  involvement  of  the  sensory  filaments. 

(<^)  Circumflex  Nerve. — The  deltoid  and  teres  minor  are  involved. 
The  arm  cannot  be  raised,  sensation  is  impaired,  and  the  deltoid  atro- 
phies. 

(f)  Muscidospiral. — This  is  affected  in  wrist-drop  from  any  cause,  as 
lead,  arsenic,  or  injury  by  pressure.  Extension  of  the  forearm,  wrist, 
and  fingers  is  lost.    Anesthesia  or  formication  may  be  present. 

(rt^)  Musculocutaneous. — In  this,  flexion  of  the  forearm  is  lost,  and  sen- 
sation may  be  affected. 

{/)  Ulnar. — Flexion  of  the  ulnar  side  of  the  wrist,  ring  and  little  fin- 
gers is  impaired,  the  thumb  cannot  be  adducted  or  the  first  phalanges 
flexed.  In  old  cases  the  main  en  griffe,  or  claw-hand,  is  produced.  Sen- 
sation is  lost  in  two  and  a  half  fingers  on  the  dorsal  side,  and  in  one 
and  a  half  on  the  palmar  side. 


634  PRACTICE  OF  MEDICINE 

(/)  Median.— The  median  nerve  is  seldom  involved  alone.  The  wrist 
cannot  be  flexed  toward  the  ulnar  side.  Abduction  of  the  thumb  and 
flexion  of  the  second  phalanges  and  the  distal  phalanges  of  the  first 
and  second  fingers  are  lost.  The  sensation  is  lost  in  the  parts  affected,' 
and  the  thumb  muscles  atrophy. 

LUMBAR  PLEXUS. 

Paralysis  or  spasm  may  affect  the  parts  supplied,  as  a  result  of 
inflammation,  psoas  abscess,  injury,  caries  of  the  vertebrae,  enlarged 
glands,  tumors,  obturator  hernia,  fecal  impaction,  or  hip-joint  disease. 
Flexion  of  the  thigh  and  extension  of  the  leg  are  impaired,  and  pain 
or  anesthesia  may  be  produced.  In  spasm,  the  thigh  is  drawn  up  over 
the  abdomen.  When  the  obturator  nerve  is  injured,  as  in  parturition, 
the  adduction  of  the  thigh  is  impaired  and  the  inner  side  is  anesthetic. 
When  the  anterior  crural  is  involved,  as  in  a  wound  or  dislocation  of 
the  hip,  the  extension  of  the  knee  is  impaired,  the  inner  side  and  front 
of  the  thigh  and  the  inner  side  of  the  leg  are  anesthetic.  Gluteal  paraly- 
sis weakens  the  abduction  of  the  thigh. 

SACRAL    PLEXUS. 

This  plexus  is  subject  to  lesions  of  the  same  character  as  those  of 
the  lumbar  plexus.  Neuritis  is,  however,  more  common,  usually  extend- 
ing upward  from  the  sciatic  nerve.  In  paralysis  the  muscles  supplied 
by  the  sciatic  are  affected.  The  flexors  of  the  leg  and  all  the  muscles 
below  the  knee  are  involved.  The  outer  half  of  the  leg  and  the  dorsum 
of  the  foot  are  anesthetic.  The  lesser  sciatic  nerve  is  seldom  affected. 
Such  involvement  is  indicated  by  paralysis  of  the  gluteus  maximus, 
producing  inability  to  rise  from  a  sitting  posture  without  difiiculty,  and 
an  area  of  anesthesia  in  the  middle  portion  of  the  back  of  the  thigh. 

SCIATICA. 

The  greater  sciatic  nerve  may  be  the  seat  of  neuralgia  or  neuritis. 
The  affection  is  more  common  in  men,  but  women  are  not  exempt.  It  is 
somewhat  more  frequent  after  the  fortieth  year,  and  many  patients  are 
the  subjects  of  gout  or  rheumatism.  It  often  follows  exposure  to  cold 
and  wet,  and  is  therefore  more  prevalent  during  the  winter  and  spring. 
Somefmes  it  follows  an  unusual  strain,  as  in  lifting.  It  may  arise  from 
the  pressure  of  a  tumor,  impacted  feces,  the  fetal  head,  or  a  hip-joint 
lesion.  The  pathological  lesions  in  the  nerve  are  a  perineuritis  and  an 
interstitial  neuritis,  most  pronounced  at  the  notch  and  middle  of  the 
thigh,  but  sometimes  extending  upward  to  the  plexus  or  to  the  cord. 

Symptoms.— Faiin  predominates.  It  usually  develops  gradually  and 
increases  in  intensity.  Sometimes,  however,  the  onset  is  sudden  and 
sharp.  At  first  confined  to  the  middle  part  of  the  back  of  the  thigh,  the 
pain  rapidly  extends  downward  to  the  entire  distribution  of  the  nerve, 
along  the  entire  leg  and  over  the  dorsum  of  the  foot.  It  is  usually  a 
constant  aching,  burning,  or  boring,  but  sometimes  paroxysmal.  The 
leg  is  partially  flexed;  the  patient,  in  attempting  to  walk,  rests  the  weight 
on  the  toes.  Extension  and  motion  increase  the  suffering.  The  external 
temperature  is  reduced  and  there  may  be  a  subjective  sense  of  coldness. 


DISEASES  OF  THE  SPINAL  CORD  635 

A  herpetic  eruption  sometimes  appears ;  formication  is  common,  anesthe- 
sia of  the  skin  unusual.  The  tender  spots  characteristic  of  neuralgia  are 
generally  found  at  the  notch,  middle  of  the  back  of  the  thigh,  popliteal 
space,  middle  of  the  calf,  sometimes  back  of  the  external  maleolus,  and  on 
the  dorsum  of  the  foot.  In  protracted  cases,  the  muscles  atrophy,  but 
the  reaction  of  degeneration  is  not  usually  present. 

Diagnosis. — Neuralgia  is  distinguished  from  neuritis  by  its  occurring 
in  younger  patients,  as  a  rule,  its  shorter  duration,  and  the  absence  of 
atrophy.  Pain  due  to  the  pressure  of  a  tumor  can  be  excluded  by 
thorough  examination  of  the  pelvis.  In  lumbago,  the  pain  is  more  con- 
fined to  the  loins,  and  there  is  tenderness  on  deep  pressure.  Hip-joint 
disease  is  recognized  through  the  pain  occasioned  by  motion  of  the 
joint.  The  pains  of  locomotor  ataxia  are  bilateral ;  loss  of  the  patellar 
reflex  and  other  symptoms  of  the  disease  are  present.  The  Achilles 
tendon-reflex  (plantar  flexion  of  the  ankle)  is  weakened  or  obliterated 
in  cases  of  sciatic  neuritis. 

Prognosis. — Ordinary  cases  recover  within  four  or  six  weeks.  Much 
depends  upon  the  season  and  weather.  Many  cases  persist  until  mid- 
summer. 

Treatment. — Rest  is  the  most  important  factor.  The  patient  should 
be  kept  in  bed,  in  severe  cases,  with  the  leg  extended  on  a  splint.  Hot 
water,  poultices,  the  cautery,  mustard,  and  blisters  afford  relief  for  a 
time.  The  same  is  true  of  ointments  and  liniments  containing  menthol, 
camphor,  chloroform,  or  aconite.  Deep  injections  of  cocain  or  of  distilled 
water,  and  acupuncture,  have  often  proved  beneficial.  Chloroform  and 
ether  have  been  injected  into  the  region  of  the  nerve  with  benefit,  but 
there  is  danger  of  producing  abscess  or  aggravating  the  neuritis.  Mor- 
phin  should  not  be  employed  if  it  can  be  avoided,  and  then  without  the 
knowledge  of  the  patient.  After  the  case  has  persisted  for  a  time,  and 
especially  if  atrophy  has  begun,  massage  and  galvanism  are  valuable 
agents.  Nerve-stretching  was  formerly  much  resorted  to,  but  the  relief 
thus  afforded  does  not,  as  a  rule,  prove  permanent.  Rheumatic  patients 
are  often  benefited  by  the  salicylates,  gouty  patients  by  colchicum.  Re- 
moval to  a  warm  climate  is  advisable  in  intractable  cases. 

Coccygodynia  is  a  neuralgia  of  the  posterior  sacral  branches  usually 
due  to  injury,  especially  to  fracture  or  dislocation  of  the  coccyx.  Pallia- 
tive treatment  consists  in  the  introduction  of  anodyne  suppositories,  but 
in  most  cases  removal  of  the  coccyx  must  be  resorted  to. 


DISEASES  OF  THE  SPINAL  CORD  AND  MENINGES. 
SPINAL  PACHYMENINGITIS. 

Definition. — Inflammation  of  the  dura  mater  of  the  spinal  cord.  Either 
the  outer  or  inner  layer  may  be  affected,  the  latter  more  frequently. 
External  and  internal  pachymeningitis  are  thus  recognized.  Inflammation 
of  the  connective  tissue  between  the  dura  and  the  bony  canal  is  known 
as  peripachymeningitis. 

Etiology. — External  pachymeningitis  is  produced  by  injury,  often  ac- 
companied with  hemorrhage,   tumors,   but  especially  by  tubercular  or 


636  PRACTICE  OF  MEDICINE 

syphilitic  caries  or  abscess  of  the  bone.    It  may  be  acute  or  chronic  and 
affects  an  area  corresponding  to  one  or  several  vertebrae. 

Internal  pachymeningitis  is  usually  an  extension  from  the  external  or 
of  inflammation  in  the  vicinity.  An  independent,  chronic,  hemorrhagic 
form  occurs,  however,  in  alcoholic  or  paretic  subjects,  after  convulsions 
in  epilepsy  or  tetanus,  or  in  connection  with  the  hemorrhagic  forms  of 
the  acute  infections.    It  involves  especially  the  cervical  portion. 

Morbid  Anatomy. — In  the  external  form,  the  dura  is  thick  and  firm. 
It  may  be  adherent  or  covered  with  a  caseous  layer.  When  hemorrhage 
has  occurred,  the  blood  generally  lies  between  the  membrane  and  the 
spinal  canal.  It  is  sometimes  referred  to  as  spinal  apoplexy.  In  the 
internal  form  the  dura  is  also  much  thickened.  In  the  hemorrhagic  form 
there  may  be  engorgement  of  blood-vessels,  punctate  hemorrhages,  or 
large  extravasations  when  the  hemorrhage  has  resulted  from  the  perfora- 
tion of  a  vessel.  A  firm-walled  blood-cyst  is  sometimes  found  filled  with 
disorganized  blood  and  pigment,  in  old  cases. 

Symptoms. —These  are  often  indefinite,  but  they  usually  suggest  myeli- 
tis. The  manifestations  are  about  the  same  in  all  forms,  (i)  There  is 
intense  neuralgic  pain  along  the  nerves  whose  roots  are  compressed, 
especially  those  of  the  arm  and  neck.  Hyperesthesia,  numbness,  and 
tingling  are  usually  present.  Spasm  of  the  muscles  of  the  neck  may 
occur.  (2)  Later,  the  hyperesthesia  may  give  place  to  anesthesia,  and 
the  muscular  contractions  to  paralysis.  Atrophy  of  the  muscles  of  the 
neck  and  arm  and  shoulder  ensues,  and,  when  the  lesion  is  high  enough 
to  involve  the  musculospiral,  there  is  wrist-drop.  (3)  Degenerative 
changes  in  the  cord  follow,  in  the  worst  cases,  producing  spastic  paraly- 
ses with  exaggeration  of  the  reflexes  and  anesthesia,  but  without  atrophy 
of  the  muscles.  Bedsores  and  paralysis  of  the  bladder  are  sometimes 
produced. 

Diagnosis. — Difiiculty  may  arise  in  the  exclusion  of  amyotrophic  lat- 
eral sclerosis,  syringomyelia,  and  compression  by  tumors.  From  the 
first  of  these  it  is  distinguished  by  the  severe  pain  in  the  arm  and  neck ; 
from  the  second,  by  the  absence  of  such  sensory  changes  as  alteration  of 
the  temperature-perception.  Tumors  cannot  always  be  excluded,  for  the 
pathological  conditions  are  often  identical. 

Prognosis. — The  disease  is  chronic,  sometimes  lasting  from  one  to 
several  years.  Recovery  is  possible,  but  a  fatal  termination  is  to  be 
expected  from  exhaustion,  septic  infection,  or  an  intercurrent  disease. 

rreafmewf.— Counter-irritation  with  blisters  or  the  cautery  is  some- 
times of  benefit.  The  ice-bag  and  internal  administration  of  ergot  reduce 
the  inflammation.    Potassium  iodid  is  often  of  service. 

SPINAL  LEPTOMENINGITIS. 

Definition. — An  acute  or  chronic  inflammation  of  the  pia  mater  of  the 
spinal  cord. 

ACUTE  LEPTOMENINGITIS. 

Etiology.— The  disease  most  frequently  occurs  in  a  secondary  relation 
to  an  acute  infection,  especially  cerebrospinal  meningitis  or  tuberculosis ; 
or  as  an  extension  of  the  inflammation  from  a  pachymeningitis  or  my- 


SPINAL  LEPTOMENINGITIS  637 

elitis;  rarely,  perhaps,  from  exposure  to  cold.  It  may  arise  from  injury 
of  the  spine. 

Morbid  Anatomy. — The  lesions  are  those  peculiar  to  an  inflamed  serous 
membrane,  hyperemia  with  opacity,  and  a  serofibrinous  or  purulent 
exudate,  most  marked  on  the  posterior  portion.  The  cord  is  occasion- 
ally involved  in  a  meningomyelitis. 

Symptoms. — The  S3^mptoms,  with  the  exception  of  a  wider  range  of 
severity,  are  the  same  as  those  of  cerebrospinal  meningitis  (p.  112)  and 
tubercular  meningitis  (p.  180).  The  differentiation  from  either  of  these 
conditions  rests  upon  a  recognition  of  the  secondary  nature  of  the  dis- 
ease and  its  dependence  upon  a  previous  infection,  inflammation,  or 
injury. 

Treatment. — The  treatment  is  that  of  cerebrospinal  meningitis. 

CHRONIC  LEPTOMENINGITIS. 

Etiology. — The  chronic  form  of  the  disease  usually  develops  independ- 
ently of  the  acute,  except  in  infants,  and  as  a  result  of  disease  of  the 
cord,  syphilis,  tuberculosis,  or  injury. 

li/lorbid  Anatomy. — The  pia  mater  is  opaque,  usually  much  thickened, 
adherent,  and  often  pigmented.  The  arachnoid  is  infiltrated  with  serum, 
and  gummatous  or  tubercular  lesions  may  be  found. 

Symptoms. — These  are  usually  limited  to  rigidity  of  the  neck,  with 
sensory  disturbances.  Paralyses  are  developed  when  the  nerve-roots  are 
involved. 

Treatment. — Potassium  iodid  should  always  be  administered  in  the 
hope  that  the  disease  is  syphilitic.  Sirup  of  the  iodid  of  iron  is  better 
in  children  and  tuberculous  cases.  Hot  and  cold  applications  and 
douches  are  often  beneficial. 


AFFECTIONS   OF   THE   BLOOD-VESSELS   AND    CIRCULA- 
TION OF  THE  CORD. 

Hyperemia.— The  occurrence  of  hyperemia,  or  congestion,  of  the  spinal 
cord  is  largely  hypothetical,  for  it  is  rarely,  if  ever,  discovered  after 
death  except  in  connection  with  myelitis.  When  seen,  it  is  usually  con- 
fined to  definite  regions  of  the  gray  matter,  which  has  generally  a  pale 
reddish  color.  There  are  no  symptoms  by  which  its  presence  can  be 
diagnosticated. 

Anemia.— Little  is  known  of  spinal  anemia.  In  the  most  profound 
general  anemias,  chlorosis  and  leukemia,  there  are  rarely  any  manifesta- 
tions on  the  part  of  the  spinal  cord.  There  is  no  positive  basis  for 
attributing  neurasthenia  to  anemia  of  the  cord.  WTien,  however,  a  pro- 
found anemia  is  suddenly  produced  by  the  loss  of  a  large  quantity  of 
blood,  as  in  hemorrhage  from  the  stomach  or  uterus,  loss  of  sphincter 
control  or  complete  paraplegia  is  not  infrequently  developed. 

Embolism  and  Thrombosis.— Embolism  of  the  vessels  of  the  cord  is 
rare,  but  may  follow  endocarditis.  Thrombosis  is  more  commonly  met 
with  as  a  result  of  endarteritis  in  either  acute  or  chronic  afi'ections  of  the 
cord. 


638  PRACTICE  OF  MEDICINE 

Arteriosclerosis  develops  in  the  spinal  cord  under  the  same  conditions 
as  elsewhere,  particularly  as  a  result  of  syphilis  or  as  a  senile  change. 
The  intima  of  the  vessel  is  much  thickened  at  the  expense  of  its  lumen. 
Miliary  aneurisms  are  much  less  frequently  produced  than  in  the  brain. 

Hemorrhage  into  the  Cord  (Hematomyelia).—£f/o/o^/.— Hemorrhage 
into  the  substance  of  the  cord  is  most  frequently  due  to  traumatism ;  it 
may,  however,  follow  exposure  to  cold,  overexertion,  excessive  coitus, 
and  such  affections  of  the  cord  as  myelitis,  syringomyelia,  and  tumors. 

Morbid  Anatomy.  — A  considerable  portion  of  the  cord  is  sometimes 
involved.  The  blood  may  be  fluid  or  clotted,  confined  to  the  gray  mat- 
ter or  it  may  extend  to  the  meninges,  after  producing  laceration  of  the 
cord  substance.  In  cases  of  long  standing  there  sometimes  remains  only 
a  pigmented  area  from  which  the  fluid  portion  of  the  blood  has  been 
absorbed. 

Symptoms. — The  symptoms  are  much  the  same  as  those  due  to  the 
pressure  caused  by  hemorrhage  into  the  meninges,  and  at  a  later  period 
resemble  myelitis.  Paraplegia  or  paralysis  of  all  the  members  is  pro- 
duced in  some  cases.  The  diagnosis  generally  rests  upon  the  suddenness 
of  the  onset,  and  the  restriction  of  the  symptoms  to  the  cord. 

The  prognosis  is  nearly  always  fatal.  In  the  few  cases  that  recover,^ 
more  or  less  permanent  paralyses  are  generally  left. 

The  treatment  is  the  same  as  that  of  hemorrhage  into  the  meninges. 

CAISSON  DISEASE. 

DIVER'S  PARALYSIS,  COMPRESSED-AIR  DISEASE. 

Definition. — A  condition  usually  characterized  by  paraplegia  or  general 
paralysis,  which  is  induced  in  caisson  and  tunnel  workers,  rarely  in 
divers,  by  too  suddenly  returning  to  the  surface. 

Etiology. — A  pressure  of  three  atmospheres  (45  pounds  to  the  square 
inch)  or  more  is  usually  maintained  in  caissons  and  deep  tunnels  in 
order  to  exclude  water.  Caisson  disease  is  produced  by  coming  suddenly 
from  a  pressure  of  more  than  three  atmospheres  to  that  of  the  external 
air.  It  does  not  occur  so  long  as  the  workman  is  under  the  pressure  or 
after  leaving  a  pressure  of  less  than  45  pounds.  Several  explanations 
have  been  given  for  the  symptoms,  the  most  plausible  being  that  they 
are  due  to  the  liberation  of  gases  which  have  been  retained  in  the  blood 
on  account  of  the  high  pressure.  The  muscular  activity  under  pressure 
probably  has  its  influence  in  some  cases. 

li/lorbid  Anatomy. — Lesions  are  not  always  discovered  in  fatal  cases. 
Punctate  hemorrhages  are  sometimes  found  in  the  thoracic  portion  of 
the  cord,  and  in  some  instances  a  condition  resembling  lacerations,  and 
fissures,  as  if  due  to  the  liberation  of  gas,  or  the  lesions  of  myelitis,  may 
be  revealed.    Corresponding  lesions  are  not  found  in  the  brain. 

Symptoms. — The  manifestations  of  the  disease  may  appear  immediately 
upon  leaving  the  caisson  or  three  or  four  hours  after.  Such  premonitory 
symptoms  as  headache,  giddiness,  and  neuralgic  pains  sometimes  precede 
the  attack  for  several  days.  In  mild  cases  the  only  symptoms  are  ago- 
nizing pains  in  the  knees,  which  subside  within  a  few  days.  Sometimes  the 
elbows  and  other  joints  are  aff'ected.   In  severe  cases  paraplegia  develops. 


MYELITIS  639 

with  diminished  sensation  or  hyperesthesia,  increased  patellar  reflex,  and 
swelling  and  soreness  of  the  muscles.  The  joints  do  not  swell.  Head- 
ache, nausea,  vomiting,  vertigo,  tinnitus,  deafness,  chilliness,  and  reten- 
tion of  urine  are  common  accompaniments.  The  urine  may  be  albumi- 
nous. Monoplegias  and  hemiplegia  have  been  exceptionally  observed,  and 
in  the  worst  cases  there  is  general  paralysis,  followed  in  a  few  hours  by 
death  in  coma. 

Prognosis. — Most  cases  recover.  The  paralysis  subsides  in  from  one  to 
three  weeks. 

7>eaf/we/7f.— Prophylaxis  requires  care  in  the  passage  from  a  high  to 
low  pressure.  A  series  of  chambers  having  graded  pressures  is  provided 
in  properly  constructed  caissons.  The  immediate  return  of  the  patient 
to  the  higher  pressure  relieves  all  symptoms,  and  he  may  then,  in  a  short 
time,  be  gradually  removed  to  the  surface.  When  this  cannot  be  done, 
the  patient  must  be  confined  to  bed.  Morphin  may  be  required  for  the 
pain ;  hot  fomentations  and  massage  ameliorate  the  suffering.  Strychnin 
should  be  administered  in  the  treatment  of  the  paralyses. 

MYELITIS. 

ACUTE,  GENERAL  OR  TRANSVERSE  MYELITIS,  WHITE    SOFTENING   OF  THE 
CORD,  INFLAMMATION  OF  THE  SPINAL  CORD. 

Definif/on.—A  localized  transverse  or  diff'use  inflammation  of  the  spinal 
cord,  followed  by  softening  or  sclerosis. 

Eiiology. — The  disease  usually  occurs  in  males  between  the  ages  of  10 
and  30  years.  It  most  frequently  follows  exposure  to  cold  and  wet,  but 
may  result  from  severe  trauma,  as  fracture  of  the  spine,  strong  muscular 
strain,  or  from  emotional  disturbance.  It  occasionally  develops  upon 
one  of  the  acute  infectious  diseases,  as  the  exanthemata,  rheumatism, 
septicemia,  or  smallpox.  It  is  sometimes  associated  with  syphilis  or 
nephritis,  and  it  may  be  induced  by  one  of  the  metallic  poisons  or 
chronic  alcoholism.  Peripheral  neuritis  and  meningitis  are  thought  to 
be  possible  causes.    A  syphilitic  history  is  frequently  obtained. 

Morbid  Anatomy. — In  transverse  myelitis  the  disease  is  limited  to  a 
small  vertical  area  extending  entirely  across  the  cord;  when  a  larger 
portion  is  affected,  it  is  termed  diffuse  myelitis.  When  several  areas  are 
involved  in  different  parts  of  the  cord,  it  is  a  disseminated  myelitis;  and 
when  only  the  gray  matter  is  aff'ected,  it  is  a  central  myelitis.  The 
disease  is  most  frequently  situated  in  the  upper  dorsal  region,  next  in 
the  cervical,  and  then  in  the  lower  dorsal;  it  rarely  affects  the  lumbar 
cord,  except  in  the  disseminated  form.  In  some  cases  the  cord  shows 
little  or  no  change  upon  ocular  inspection,  while  in  other,  advanced 
cases  it  is  extremely  soft,  almost  diffluent,  or  greatly  hardened,  sclerotic, 
owing  to  the  proliferation  of  interstitial  connective  tissue.  The  cord  may 
appear  swollen,  the  membranes  congested,  the  fibers  in  a  state  of  yellow 
atrophy  (the  color  being  due  to  pigmentation),  or  there  may  be  fatty 
degeneration  in  cases  of  long  standing.  In  central  myelitis  there  is  often 
red  softening,  occasionally  also  small  cavities.  Such  new  elements  as  the 
so-called  Deiter's  "spider"  cells  and  granular  fatty  masses  may  be  found. 
Amylaceous  bodies  are  not  uncommon.    The  nerve  fibers  and  cells  may 


640  PRACTICE  OF  MEDICINE 

"be  swollen  and  disintegrated  in  the  lesions  and  for  some  distance  above 
and  below  them.  Blood-corpuscles  are  sometimes  present.  Obliterative 
arteritis  is  observed  in  some  cases. 

Symptoms. — The  onset  may  be  acute  with  fever,  subacute,  or  chronic. 
Convulsions  may  occur  in  children.  The  manifestations  vary  with  the 
portion  of  the  cord  affected.  Such  premonitory  symptoms  as  numbness, 
tingling,  formication,  and  weight  or  girdle  pains  may  be  present,  but,  as 
a  rule,  the  motor  disturbances  precede  the  sensory.  The  first  symptoms 
are  irritative ;  they  may  be  motor,  sensory,  vesical,  or  rectal.  A  girdle 
sensation  corresponding  to  the  location  of  the  lesion  soon  develops,  and 
a  partial  or  complete  paraplegia  follows.  Hyperesthesia  may  be  present, 
especially  in  the  zone  above  the  girdle,  but  in  a  short  time  all  sensation 
is  lost  in  the  parts  affected.  The  application  of  heat  to  the  hyperesthetic 
area  occasions  a  sensation  of  pain.  WTien  the  myelitis  extends  to  the 
cervical  spine,  the  power  of  motion  is  lost  in  the  upper  extremities.  The 
reflexes,  both  of  the  tendons  and  of  the  skin,  are  diminished  or  obliter- 
ated in  the  beginning,  but  later  become  exaggerated,  except  in  central 
myelitis,  when  they  are  lost  unless  the  disease  be  confined  to  the  cervical 
and  upper  dorsal  region.  The  electrical  reactions  generally  remain  nor- 
mal, but  the  reaction  of  degeneration  is  sometimes  obtained.  When  the 
centers  of  the  sphincters  are  involved,  there  is  involuntary  fecal  evacua- 
tion and  incontinence  of  urine  from  overdistention  of  the  bladder.  Atro- 
phic changes  are  unusual.  The  muscles  become  soft  and  relaxed,  but 
there  is  little  atrophy  except  when  the  gray  matter  is  involved.  Rigidity 
often  occurs.  Bedsores  frequently  develop  early ;  they  are  superficial  and 
not  regarded  as  trophic.  In  chronic  cases,  however,  deep  sloughs  of  this 
character  may  occur.  Optic  neuritis  is  sometimes  observed  in  these 
cases. 

The  duration  of  the  disease  varies  from  a  few  days  to  several  years. 
Apparent  improvement  may  occur,  but,  as  a  rule,  the  disease  becomes 
chronic  and  the  patient  is  left  a  hopeless  paralytic,  greatly  tormented 
at  times  by  muscular  twitching,  spasm,  or  flexures,  involuntary  evacua- 
tions of  urine  and  feces,  and  bedsores.  Recurrent  cases  are  occasionally 
encountered.  In  another  group  spontaneous  recovery  occurs  after  a 
year  or  more  of  complete  rest. 

Acute  central  myelitis  is  distinguished  by  a  more  violent  onset,  with 
hyperpyrexia,  sometimes  with  convulsions  and  complete  paralysis.  The 
course  is  rapid  and  usually  fatal. 

In  transverse  myelitis  of  the  cervical  cord  as  high  as  the  sixth  or 
seventh  vertebra,  the  upper  extremities  are  more  or  less  completely  par- 
alyzed, and  sensation  is  gradually  lost.  In  some  instances,  however, 
only  the  arms  are  involved,  and  the  shoulder  muscles  sometimes  escape. 
Vomiting,  hiccough,  slow  pulse,  contracted  pupils  (miosis),  dysphagia, 
dyspnea,  and  syncope  are  sometimes  met  with. 

Diagnosis. — Acute  ascending  paralysis  is  excluded  in  the  diagnosis  of 
central  myelitis,  which  it  most  resembles,  by  the  less  marked  sensory  and 
trophic  disturbances  and  the  absence  of  fever.  In  multiple  netiritis  there 
is  not  usually  so  marked  anesthesia,  and  the  control  of  the  sphincters  is 
not  usually  lost.  Tumors  and  hemorrhages  of  the  cord  are  sometimes 
difficult  or  impossible  of  diagnosis,  from  the  fact  that  they  produce  a 
form  of  pressure  myelitis. 


MYELITIS  641 

Prognosis. — An  acute  case  may  terminate  fatally  within  a  week ;  chronic 
cases  are  often  protracted  for  one  or  two  years. 

Treatment. — In  the  more  acute  cases  the  spinal  cord  must  be  given 
complete  rest,  and  the  patient  must,  therefore,  be  confined  to  bed.  This 
necessitates  the  greatest  care  and  the  exercise  of  scrupulous  cleanliness 
in  order  to  avoid  the  development  of  bedsores.  In  chronic  cases  the 
patient  may  take  such  exercise  as  he  can,  short  of  fatigue.  He  may  be 
able  to  propel  himself  in  a  rolling-chair,  but  should  always  sit  upon  an 
air  or  water  cushion.  Catheterization  is  usually  necessary,  and  should  be 
done  with  due  regard  to  cleanliness  and  the  avoidance  of  cystitis.  If 
incontinence  persist,  the  patient  should  wear  a  urinal.  Little  or  nothing 
can  be  done  to  modify  the  condition  in  the  spinal  cord.  Ice-bags,  coun- 
ter-irritation, blisters,  and  cupping  are  recommended,  but  they  are  of 
doubtful  benefit.  Mercury  and  potassium  iodid  are  of  doubtful  utility, 
even  in  syphilitic  cases,  for  they  cannot  restore  the  destroyed  tissues.  It 
is  quite  probable  that  the  cases  which  recover  do  so  independently  of 
treatment.  Strychnin  should  be  administered,  however,  in  full  doses, 
gr.  1-40  to  1-20  (0.0016 — 0.0032),  in  order  to  stimulate  the  nerve-cen- 
ters to  action;  and  after  voluntary  motion  has  been  restored,  the  fa- 
radic  current  and  massage  of  the  muscles  are  of  great  value.  Quinin 
and  arsenic  are  also  esteemed  for  their  tonic  effects. 

COMPRESSION  OF  THE  SPINAL  CORD. 

COMPRESSION  MYELITIS. 

Definition. — Arrest  of  the  functions  of  the  cord,  with  or  without  in- 
flammation, as  a  result  of  compression. 

Etiology. — The  cord  may  be  compressed  in  any  part  in  individuals  of 
any  age.  The  principal  causes  are  fracture  of  the  spine  and  tubercular 
caries  (Pott's  disease).  It  may  be  due  to  gummata,  malignant  neo- 
plasms, abscess,  hemorrhage,  thickening  or  purulent  exudates  of  the  me- 
ninges, thoracic  or  abdominal  aneurism,  echinococcus  and  other  cysts, 
retropharyngeal  abscess,  extreme  lateral  curvature  (scoliosis)  or  spina 
bifida. 

IVIorbid  Anatomy. — The  cord  may  be  compressed  or  bent  so  as  to  lose 
its  normal  appearance  without  necessarily  showing  inflammatory  changes. 
In  some  cases,  however,  there  are  punctiform  hemorrhages,  degeneration 
of  nerve  fibers,  and  proliferation  of  neuroglear  cells.  In  old  cases  de- 
generative changes  can  be  traced  upward  and  along  the  cord  from  the 
primary  lesion. 

Symptoms. — i.  Vertebral  Syniptoins. — Various  deformities  follow  frac- 
ture, vertebral  caries,  growth  of  tumors,  or  other  causal  conditions.  The 
disease  sometimes  develops  rapidly,  and  terminates  fa,tally  through  ero- 
sion of  the  vertebral  artery.  Pain  is  present  in  all  cases,  and  it  is  espe- 
cially severe  in  those  due  to  aneurism  or  other  tumor.  Local  tenderness 
is  usually  present,  and  the  slightest  jar  causes  pain. 

2.  Nerve-Root  Symptoms. — These  differ  as  different  nerve-roots  are  in- 
volved in  their  outward  passage  between  the  vertebrae.  They  consist  for 
the  most  part  of  radiating  peripheral  neuralgic  pains.  Exquisitely 
painful  areas  (anesthesia  dolorosa)  are  sometimes  developed,  especially 
in    secondary    cancer    of  the    spine.    Atrophy    of  the  muscles  supplied 

41 


642  PRACTICE  OF  MEDICINE 

through  the  affected  roots  often  follows,  but  in  a  large  group  of  cases 
attended  with  extensive  vertebral  disease  the  nerve-roots  escape. 

3.  Cord  Symptoms. — These  vary  with  the  region  affected.  There  may 
be  paraplegia  or  paralysis  of  all  the  extremities  (quadruplegia),  dyspnea 
from  involvement  of  the  phrenic  nerve,  dilatation  of  the  pupils,  trophic 
and  vasomotor  disturbances,  as  muscular  atrophy,  cutaneous  eruptions 
and  desquamations,  bedsores,  sweating,  and  alterations  of  local  tempera- 
ture. The  sphincters  may  be  paralyzed,  a  girdle  sensation  may  be  pres- 
ent, and  other  symptoms  like  those  of  subacute  or  chronic  myelitis  are 
commonly  observed. 

The  diagnosis  rests  upon  a  careful  study  of  the  symptoms  and  the 
discovery  of  the  underlying  condition.  The  pain  is  most  severe  in  cases 
due  to  aneurism,  and  the  nerve-roots  are  more  constantly  affected  in 
malignant  cases.  The  symptoms  are  often  obscure  in  tuberculous  cases, 
but  in  these,  as  in  those  due  to  syphilis,  there  are  usually  other  lesions 
and  a  definite  history  of  infection.  Persistent  lumbago,  Janeway  states, 
is  a  significant  sign  of  vertebral  caries  in  some  cases. 

Prognosis. — Cases  due  to  tubercular  caries  sometimes  become  quiescent 
and  those  due  to  syphilis  may  subside  under  treatment,  but  in  all  other 
conditions  the  prognosis  is  exceedingly  unfavorable. 

Treatment. — Tubercular  cases  should  be  treated  according  to  the  gen- 
eral methods  for  tuberculosis,  with  the  addition  of  orthopedic  appliances 
for  the  removal  of  pressure  and  the  prevention  or  correction  of  deformity. 
Confinement  to  bed,  with  extension,  is  often  necessary  for  a  time.  Cases 
due  to  gummata  are  generally  relieved  by  potassium  iodid.  Excision  of 
the  vertebral  laminae  (laminectomy)  has  proved  beneficial.  In  hopeless 
cases,  as  those  due  to  tumors,  morphin  should  not  be  withheld,  and  every 
effort  should  be  made  for  the  prevention  of  bedsores  and  excoriations. 

ACUTE  ANTERIOR  POLIOMYELITIS. 

I.  ACUTE  ANTERIOR  POLIOMYELITIS  OF  CHILDREN. 
Infantile  Spinal  Paralysis,  Essential  or  Atrophic  Paralysis  of  Children, 

Definition. — An  acute,  febrile  disease  affecting  the  gray  matter  of  the 
anterior  horns  of  the  spinal  cord  of  young  children,  and  producing  pa- 
ralysis of  certain  muscles,  followed  by  rapid  atrophy  of  them. 

Etiology. — The  disease  usually  appears  before  the  fourth  year  of  life 
and  in  previously  healthy  children  of  either  sex.  It  rarely  occurs  in 
adults,  mostly  males.  It  is  often  erroneously  attributed  to  injury,  as 
by  a  fall.  It  is  sometimes  attributed  to  cold,  dentition,  muscular  exer- 
tion, or  mental  strain.  Most  cases  occur  in  summer,  and  for  this  reason, 
in  part,  but  more  particularly  because  the  disease  has  appeared  in 
epidemic  form,  it  has  been  regarded  by  some  writers  as  an  infection.  It 
may  follow  acute  disease,  menstrual  suppression,  sexual  excess,  dissipa- 
tion, or  syphilitic  infection. 

Morbid  Anatomy.— The  essential  lesion  is  an  acute  hemorrhagic  mye- 
litis in  the  cervical  or  lumbar  enlargement.  Degeneration  follows,  with 
rapid  destruction  of  the  ganglion  cells,  the  growth  of  sclerotic  tissue, 
vascular  dilatation,  and  endarteritis.  The  disease  is  believed  to  originate 
probably  as  an  embolism  or  thrombosis,  in  the  ventral  spinal  artery. 


ACUTE  ANTERIOR  POLIOMYELITIS  643 

usually  of  one  side,  rarely  of  both ;  since  the  lesions  correspond  to  the  dis- 
tribution of  its  terminal  or  cornual  branches.  The  cord  is  more  or  less 
deformed  as  a  result  of  atrophy  and  sclerosis.  The  affected  muscles  also 
undergo  degenerative  changes,  and  the  interstitial  tissue  becomes  sclerotic. 

Symptoms. — The  invasion  is  abrupt,  or  preceded  by  slight  fever  and 
malaise  for  a  day  or  two.  The  course  of  the  disease  may  be  acute,  sub- 
acute, or  chronic.  The  first  recognizable  symptom,  as  a  rule,  is  paralysis 
of  one  or  more  hmbs.  Convulsions  very  rarely  occur.  The  paralysis 
becomes  complete  within  24  hours,  and  the  affected  member  is  generally 
hyperesthetic  and  painful.  In  some  instances,  however,  the  disease  pro- 
gresses more  slowly.  When  more  than  one  part  is  affected,  the  lesions 
are  not  symmetrical,  except  occasionally  in  adults.  Monoplegia  is  the 
rule,  with  many  exceptions,  in  children;  paraplegia  in  adults.  All  the 
muscles  of  a  limb  are  not  usually  affected  to  the  same  degree,  and  only 
a  certain  group  may  be  involved,  especially  in  the  upper  extremity. 
Crossed  paralyses  are  peculiarly  common  to  this  disease.  The  paralyzed 
muscles  undergo  atrophy  within  a  few  days.  Sensation  is  not  affected, 
but  the  reflexes  are  obliterated  in  the  affected  limb,  and  the  electrical 
reaction  of  degeneration  is  early  established.  The  essential  feature  of 
this  reaction  is  a  sluggish  contraction  of  the  muscle  in  a  state  of  degen- 
eration or  supplied  by  a  degenerated  nerve  to  the  galvanic  current.  The 
contraction  is  not  instantaneous,  as  in  health,  but  it  may  be  induced  by 
a  weaker  current,  and  the  anode-closure  contraction  may  be  greater  than 
the  cathode-closure  contraction.  The  less  important  features  are  an 
absence  of  response  on  the  part  of  the  muscles  to  the  faradic  current  and 
a  failure  of  the  nerve  to  react  to  either  the  galvanic  or  faradic  current. 

After  a  week  or  two,  less  frequently  after  three  or  four  days,  recession 
of  the  paralysis  occurs  in  some  or  all  of  the  muscles,  but  complete  res- 
toration of  voluntary  motion  is  seldom,  if  ever,  obtained.  Later  the 
affected  limb  falls  behind  the  sound  one  in  its  growth,  and  muscular 
contractures  increase  the  apparent  shortening  and  deformity.  All  the 
forms  of  talipes  are  produced  in  different  cases.  The  head  of  the  humerus 
sometimes  slips  from  its  place,  owing  to  weakness  of  the  deltoid. 

Prognosis. — Error  is  rarely  possible.  Multiple  neuritis  seldom  occurs 
in  young  children.  It  affects  the  peripheral  muscles  of  the  limbs  sym- 
metrically and  is  accompanied  with  sensory  disturbances.  In  the  pseudo- 
paralysis of  rickets  the  legs  are  usually  affected,  but  the  motion  is 
restricted  on  account  of  pain,  the  power  is  not  lost,  and  the  muscles  do  not 
atrophy.  The  rachitic  prominences  lipon  the  head  and  joints,  and  along 
the  sternum,  the  hyperesthesia  and  sweating,  assist  in  the  diagnosis. 

Prognosis. — The  general  health  is  not  impaired,  except  by  the  loss  of 
exercise.  Complete  recovery  cannot  be  promised,  but  a  great  deal  can 
be  accomplished  by  persistent  efforts  for  the  improvement  of  the  par- 
alyzed members. 

Treatment. — The  patient  should  be  made  comfortable  in  the  beginning 
by  bandaging  the  affected  limb  loosely  in  a  thick  la)^er  of  cotton.  A 
purgative  dose  of  magnesium  citrate  should  be  administered.  Excessive 
fever  should  be  reduced  by  cool  sponging.  Morphin  is  rarely  required 
for  the  pain.  Sodium  bromid  may  be  given  for  the  restlessness.  The 
fluid  extract  of  ergot  should  be  administered  in  doses  of  Tl|x  to  xx  (0.60 — 
1.20)  t.  i.  d  for  the  first  week.   Counter-irritation  over  the  spine  only  adds 


644  PRACTICE  OF  MEDICINE 

to  the  suffering  and  accomplishes  nothing.  As  soon  as  the  acute  symp- 
toms have  subsided,  a  regular  course  of  treatment  by  massage  and 
electricity  should  be  begun.  A  mild  galvanic  current  should  be  applied 
at  least  twice  a  week  to  the  spine  and  the  affected  muscles.  The  case 
should  not  be  abandoned  as  hopeless  for  several  years.  Orthopedic 
treatment  is  often  necessary  for  relief  of  the  deformity.  The  nutrition 
of  the  child  must  be  maintained  with  proper  food,  codliver  oil,  and  malt 
preparations. 

2.  ACUTE  POLIOMYELITIS  IN  ADULTS. 

When  the  disease  occurs  in  adults,  it  does  not  differ  materially 
from  that  of  children,  except  in  the  more  frequent  occurrence  of  sym- 
metrical paralyses,  as  paraplegia  or  quadruplegia.  Multiple  neuritis  is 
probably  mistaken  for  this  disease  in  some  instances,  although  its  onset 
is  usually  less  sudden,  the  atrophy  is  less  rapid  and  less  profound,  and  the 
reaction  of  degeneration  is  very  exceptionally  present.  When  complete 
recovery  follows  a  doubtful  case,  the  diagnosis  of  multiple  neuritis  is 
established. 

ACUTE  ASCENDING  PARALYSIS. 

LANDRY'S  PARALYSIS. 

Definition. — An  acute  paralysis  beginning  in  the  legs  and  extending 
rapidly  upward  to  the  trunk,  arms,  neck,  and  face,  ultimately  involving 
the  muscles  of  respiration,  and  generally  terminating  fatally. 

Eiiology. — Men  between  20  and  30  years  of  age  are  generally  affected. 
Little  is  known  of  the  cause,  and  pathological  lesions  have  seldom  been 
found.  The  disease  sometimes  follows  an  acute  infection,  and  it  has  been 
regarded  as  a  peripheral  neuritis.  A  plausible  theory  is  that  it  is  pro- 
duced by  a  toxic  agent  affecting  the  lower  motor  neurons.  Some  authors 
look  upon  it  as  purely  functional  in  character. 

Symptoms. — The  first  manifestation  of  the  disease  is  usually  a  weak- 
ness of  the  legs,  which  develops  into  complete  paralysis,  often  within  a 
few  hours.  The  muscles  of  the  trunk,  arms,  neck,  and,  finally,  those  of 
respiration,  deglutition,  and  articulation  are  affected  in  rapid  succession. 
The  entire  course  of  the  disease  in  fatal  cases  may  occupy  only  two  or 
three  days,  and  it  rarely  extends  over  more  than  two  weeks.  The  muscles 
do  not  atrophy,  and  the  electrical  reactions  may  remain  normal;  the 
reflexes  are  lost.  The  sensation  may  be  normal  or  slightly  impaired. 
The  sphincters  are  not  involved,  profound  dyspnea  is  induced  when  the 
respiratory  muscles  become  implicated,  respiration  being  carried  on  solely 
by  the  diaphragm.  The  mind  and  organs  of  special  sense  escape.  The 
spleen  and  lymph-glands  are  sometimes  moderately  enlarged,  and  albu- 
minuria has  been  noted. 

Diagnosis. — The  diseases  to  be  excluded  are  myelitis,  especiall}^  the 
acute  central  form,  anterior  poliomyelitis,  neuritis,  and  possibly  the  par- 
alytic form  of  hydrophobia.  From  all  these  the  distinction  is  based 
upon  the  rapid  ascent  of  the  paralysis,  the  great  predominance  of  motor 
symptoms,  if  not  entire  absence  of  sensory  manifestations,  the  presence 
of  fever,  and  absence  of  electrical  changes  or  sphincter  involvement. 

Prognosis. — The  disease  usually  terminates  fatally  within  a  few  days, 
sometimes  not  for  several  weeks,  from  involvement  of  the  bulbar  centers 


PROGRESSIVE  MUSCULAR  ATROPHY  645 

controlling  the  action  of  the  heart.    Recovery  is  possible  only  when  the 
disease  stops  before  it  reaches  the  medulla. 

Treatment. — The  patient  should  be  given  complete  rest  and  freedom 
from  noise  or  other  disturbance.  Ergot  should  be  given  in  conjunction 
with  potassium  iodid.  Quinin  proves  beneficial  in  some  cases.  It  may 
be  given  in  doses  of  gr.  ij  to  iij  (o.io — 0.20)  three  or  four  times  a  day 
along  with  the  other  remedies.  If  the  case  does  not  terminate  fatally, 
the  after-treatment  is  the  same  as  that  of  poliomyelitis  or  multiple 
neuritis. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

CHRONIC     POLIOMYELITIS,    WASTING    PALSY,    ARAN-DUCHENNE    TYPE    OF 

MUSCULAR  ATROPHY. 

Definition. — A  progressive'  atrophy  of  the  muscles,  generally  combined 
with  paralysis  and  spastic  rigidity,  due  to  degeneration  of  the  motor 
tract  of  the  cord. 

Etiology. — The  disease  usually  affects  men  between  20  and  60,  develop- 
ing after  exposure  or  during  convalescence  from  an  acute  infection,  as 
typhus  or  typhoid  fever  or  diphtheria.  A  hereditary  tendency  can  some- 
times be  traced.  Syphilis,  lead-poisoning,  or  occupational  strain  of  partic- 
ular muscles  may  lead  to  its  development. 

IVIorbid  Anatomy. — The  essential  lesion  is  a  degeneration  of  the  motor 
neurons  of  the  lower  segments  of  the  cord,  subsequently  extending  also 
to  those  of  the  upper  segments.  The  muscles  at  the  same  time  undergo 
degeneration  and  atrophy,  with  hyperplasia  of  their  connective  tissue 
(sclerosis).  A  distinct  atrophic  degeneration  of  the  anterior  columns  of 
the  cord  is  often  visible,  and  the  microscope  reveals  atrophy  or  destruc- 
tion of  the  multipolar  ganglion  cells.  A  similar  change  extends  to  the 
gray  matter  of  the  medulla.  The  neuroglia  undergoes  hyperplasia,  which 
extends  to  the  lateral  columns  in  the  so-called  amyotrophic  lateral 
sclerosis.  In  rare  instances  the  degeneration  can  be  traced  to  various 
levels  in  the  motor  areas  of  the  brain,  and  the  cortical  centers  may  show 
degeneration. 

Symptoms. — The  disease  advances  slowly  and  is  for  a  time  confined  to 
groups  of  muscles  in  the  upper  extremities,  much  more  frequently  on  the 
right  side  than  the  left.  It  occasionally  begins  in  the  legs,  and  rarely 
affects  all  the  muscles  except  those  of  the  eyeball  and  jaw.  The  onset 
may  be  preceded  by  pains  like  those  of  chronic  rheumatism.  The  hands 
are  generally  first  affected;  the  ball  of  the  thumb  becomes  soft  and 
wasted,  then  the  interossei  and  lumbricales,  and  the  characterist'ic  claw 
hand  is  finally  produced.  In  the  forearm  the  flexors  precede  the  ex- 
tensors; in  the  shoulder  the  deltoid  is  first  affected,  and  sometimes  it  is 
the  first  to  be  involved  in  the  upper  extremity.  The  disease  generally 
skips  some  of  the  muscles,  and  these  falsely  appear  hypertrophied.  Even 
the  bones  seem  abnormally  large  in  an  advanced  stage  of  the  disease. 
Sensory  disturbances  are  not  usually  observed.  The  atrophied  muscles 
show  a  fibrillary  twitching,  which  is  intensified  by  percussion  or  a  draught 
of  air.  The  reflexes  are  greatly  increased,  and  it  is  in  this  disease  that  a 
jaw-clonus  can  oftenest  be  obtained.  The  excitability  of  the  nerves  may 
remain  after  the  muscles  have  become  completely  paralytic,  and  a  partial 
reaction  of  degeneration  is  generally  obtained.     There  is  often  a  feeling 


646  PRACTICE  OF  MEDICINE 

of  numbness  and  coolness  in  the  affected  limbs.  Sweating  is  often  in- 
creased, the  skin  becomes  harsh  and  pigmented,  the  nails  curved  and 
brittle,  from  trophic  change. 

In  the  tonic  form  of  the  disease,  the  amyotrophic  lateral  sclerosis  of 
Charcot,  an  interesting  form  of  spastic  paraplegia  is  sometimes  observed. 
When  the  patient  starts  to  walk,  he  is  unable  to  step.  After  a  moment's 
hesitation  he  takes  several  rapid  short  steps  with  the  body  inclined  for- 
ward, then  walks  at  a  rapid  gait  until  he  attempts  to  turn,  when  the 
process  must  generally  be  repeated.  The  wasting  of  the  muscles  in  this 
form  is  less  than  in  the  atrophic. 

As  the  disease  extends  upward  in  the  spine,  the  symptoms  of  bulbar 
paralysis  are  produced,  and  the  patient  may  still  later  become  demented. 

Three  other  types  of  the  disease,  described  also  as  muscular  dystro- 
phies, are  occasionally  encountered.  These  are  :  (<;?)  Erb's  juvenile  type, 
usually  hereditary,  occurring  in  young  patients  and  similar  to  the  atro- 
phic, except  that  muscular  tremors  and  the  reaction  of  degeneration 
are  absent ;  (Ji)  the  facial  type  of  infants,  beginning  as  an  atrophy  of  the 
muscles  of  expression.  The  eyes  show  animation  and  seem  to  protrude, 
but  the  muscles  respond  but  slightly  in  an  attempt  to  smile.  The  dis- 
ease usually  extends  to  the  shoulders;  (t-)  the  peroneal  type  (Charcot, 
Marie,  Tooth).  This  begins  in  the  legs,  and  several  years  later  attacks 
the  hands  and  forearms.  Clubfoot  is  often  produced.  The  duration  of 
the  disease  is  from  5  to  25  years  or  longer. 

Diagnosis. — In  chronic  myelitis  the  paralysis  precedes  the  atrophy,  and 
contiguous  muscles  are  affected.  The  same  is  true  of  simple  neuritis. 
There  are  also  in  some  cases  pain  and  hyperesthesia.  The  pain  and  sen- 
sory disturbances  of  multiple  neuritis  suffice  for  its  exclusion,  and  the 
atrophy  is  never  primary.  Muscular  pseudohypertrophy  may  cause  con- 
fusion in  the  early  stages,  but  the  hypertrophy  always  affects  the  lower 
extremities,  and  the  defective  movements  are  not  seen  in  the  apparently 
atrophic  muscles.  Syringomyelia  cannot  always  be  differentiated,  but,  as 
a  rule,  the  sensory  disturbances  enable  one  to  recognize  it. 

The  prognosis  is  always  unfavorable.  A  few  cases  of  recovery  have 
been  reported. 

Treatment. — Strychnin  should  be  given  in  full  doses,  and  the  vitality 
of  the  muscles  should  be  further  stimulated  as  long  as  possible  by 
faradization,  with  an  occasional  application  of  the  galvanic  current,  and 
massage.  The  patient  should  live  in  the  open  air  and  take  light  and 
regular,  exercise.  The  needle  bath  and  other  methods  of  hydrotherapy 
should  be  tried,  and  nutrition  must  be  maintained.  Gowers  favors  the 
use  of  arsenic.  Potassium  iodid  and  mercury  must  be  employed  in  cases 
having  a  syphilitic  taint. 

GLOSSOLABIOLARYNGEAL  PARALYSIS. 

PROGRESSIVE  BULBAR  PARALYSIS. 

Definition. — A  progressive  paralysis  and  atrophy  of  the  muscles  of  the 
tongue,  lips,  and  larynx. 

Etiology. — The  disease  rarely  occurs  in  those  under  40.  It  is  most 
common  in  men  of  neurotic  type.  Syphilis,  alcoholism,  and  mental  strain 
are  predisposing  causes. 


POSTERIOR    SPINAL   SCLEROSIS  647 

Morbid  >l/7afo/n/.— Degenerative  changes  are  found  in  the  nuclei  of  the 
hypoglossal,  facial,  spinal  accessory,  and  vagus,  and  in  the  anterior 
pyramids.  The  lesions  are  identical  with  those  of  progressive  muscular 
atrophy,  and  the  symptoms  of  the  latter  disease  are  often  present. 

5/myofo/ws.— Prodromal  numbness  in  the  back  of  the  neck  or  slight 
pain  has  been  noted,  but  it  is  unusual.  The  first  symptom  is  generally  a 
difficulty  in  the  pronunciation  of  the  labials,  dentals,  and  linguals  :  /,  b; 
/,  d;  /,  m,  etc.  As  the  lower  lip  becomes  affected,  it  droops  and  the 
saliva  escapes.  The  food  collects  between  the  lip  or  the  cheek  and  the 
gums.  Mastication  and  deglutition  soon  become  difficult,  for  the  tongue 
is  unable  to  propel  the  bolus  into  the  fauces,  and  the  food  is  often 
regurgitated  into  the  nares.  Then  the  voice  becomes  feeble  and  nasal. 
The  patient  becomes  emotionate  and  neurasthenic.  The  affection  of  the 
facial  muscles  causes  partial  loss  of  expression,  and  the  nasolabial  folds 
are  deepened.  The  involvement  of  the  pneumogastric  causes  alteration 
of  the  heart's  action  and  dyspnea. 

Diagnosis.  —The  conditions  most  Hkely  to  be  confounded  with  the  dis- 
ease are  cerebral  hemorrhage,  especially  bulbar  hemorrhage,  multiple  scle- 
rosis, and  possibly  facial  trophoneurosis.  From  all  these,  however,  it 
is  readily  distinguished  by  its  slow  development  and  progress,  the  sym- 
metry of  the  lesions,  and  the  reaction  of  degeneration. 

Prognosis.— Recovery  probably  never  occurs,  but  the  course  of  the 
disease  is  often  slow,  and  interrupted  by  intervals  of  more  or  less  com- 
plete remission.  Death  is  seldom  delayed  beyond  five  years,  however, 
and  may  occur  at  any  time  as  a  result  of  aspiration  pneumonia  from  the 
entrance  of  food  into  the  trachea,  or  from  asphyxiation  due  to  its  lodg- 
ment in  the  larynx. 

Treatment— K  medication  be  employed,  it  should  be  the  same  as  for 
progressive  muscular  atrophy.  It  is  more  important,  however,  to  main- 
tain the  nutrition  and  strength  by  a  concentrated  liquid  diet.  After  the 
patient  becomes  unable  to  swallow,  gavage  must  be  resorted  to. 

THE   SPINAL   SCLEROSES. 
POSTERIOR  SPINAL  SCLEROSIS. 

LOCOMOTOR  ATAXIA,  TABES  DORSALIS. 

Definition.— A  chronic  disease  characterized  by  degeneration  and  scle- 
rosis of  the  posterior  columns  of  the  spinal  cord,  producing  inco-ordina- 
tion,  sensory  and  trophic  disturbances,  and  sometimes  associated  with 
degeneration  of  the  spinal  ganglia  and  peripheral  nerves. 

Etiology. — The  disease  occurs,  as  a  rule,  in  men  between  30  and  40,  and 
particularly  in  those  who  have  at  some  time  been  the  subjects  of  syphilis. 
Exposure  to  cold  and  wet,  fatigue,  dissipation,  sexual  excess,  and  in- 
jury are  often  contributing  influences,  any  one  of  which  may  induce  the 
disease  in  a  syphilitic  subject,  even  though  that  disease  may  have  been 
dormant  for  many  years. 

Morbid  Anatomy.— The  disease  begins  as  a  degeneration  of  the  pos- 
terior root-zones.  From  the  several  sets  of  fibers  the  degeneration  ad- 
vances into  the  tract  of  Lissauer  and  the  columns  of  Burdach,   Clark, 


648  PRACTICE  OF  MEDICINE 

and  GoU,  and  the  fibers  are  ultimately  replaced  to  a  great  extent  hy 
connective  tissue  the  contraction  of  which  causes  compression  of  the 
cord.  Several  investigators  trace  the  beginning  of  the  disease  a  step 
further  to  a  chronic  inflammation  of  the  pia  mater.  The  nerve-fibers 
are  very  unequally  affected  in  some  cases,  one  set  showing  an  early  stage 
of  degeneration,  while  another  is  far  advanced  in  the  sclerotic  process. 
Finally,  the  entire  posterior  columns  become  converted  into  a  mass  of. 
connective  tissue  containing  few  remnants  of  nerve-fibers.  In  some  ad- 
vanced cases  the  anterolateral  ascending  tract  is  involved  and  a  periph- 
eral neuritis  is  developed,  particularly  in  the  sciatic  nerve,  sometimes 
in  the  optic,  fifth,  sixth,  eighth  pneumogastric,  and  glossopharyngeal. 
The  articular  affections  are  attributed  to  asymmetrical  lesions  sometimes 
found  in  the  anterior  columns.  Lesions  are  occasionally  found  within 
the  cranium. 

Symptoms. — ^The  course  of  the  disease  is  exceedingly  chronic  and  by 
no  means  uniform ;  it  may  last  for  many  years,  or  it  may  terminate  at 
any  stage  through  various  accidental  complications.  The  symptoms  are 
conveniently  considered  under  three  heads,  corresponding  to  different 
stages  of  the  disease.  These  stages  are  not  separated  by  distinct  lines, 
and  there  is  great  diversity  in  their  sequence. 

(i)  Initial  or  Preataxic  Stage.— Sensory  symptoms  are  often  first  to 
be  recognized,  and  one  of  the  most  common  is  pain.  This  is  manifested 
in  the  form  of  sudden,  spontaneous,  often  atrocious,  darting,  or  "  light- 
ning" pains,  shooting  down  the  arms  or  thighs,  or  visceral  and  affecting 
the  stomach  and  bowels.  The  latter  form  is  usually  accompanied  with 
violent  retching  and  vomiting  independent  of  the  ingestion  of  food,  and 
constitutes  the  gastric  crises.  In  the  same  manner  crises  may  affect  the 
heart,  larynx,  kidneys,  bladder,  urethra,  clitoris,  or  rectum.  These 
crises  may  precede  other  symptoms  for  several  years.  Paresthesia  is 
often  an  early  symptom,  alone  or  associated  with  the  pain  and  other 
manifestations.  It  usually  begins  as  a  numbness,  tinghng,  itching, 
creeping  (formication),  or  burning  in  the  feet  and  legs.  A  highly  char- 
acteristic complaint  is  an  absence  of  normal  sensation  in  the  soles.  The 
patient  feels  in  walking  as  if  he  were  treading  upon  a  soft  carpet  or 
upon  the  air.  The  hands  may  be  involved  early  or  late,  and  he  experi- 
ences difficulty  in  executing  delicate  movements,  as  in  tying  a  cravat  or 
buttoning  his  clothing,  and  his  handwriting  is  altered.  The  tactile  sense 
is  affected  so  that  the  sense  of  pain,  as  that  of  a  pin-prick,  travels  slowly 
and  may  be  referred  to  the  wrong  extremity  or  to  both.  The  tempera- 
ture sense  may  be  impaired  or  completely  lost.  A  feeling  of  constriction, 
or  girdle  pain,  is  sometimes  experienced  at  the  wrist,  knee,  or  ankle. 

Loss  of  the  patellar  reflex,  or  knee-jerk,  is  a  valuable  and  early  symp- 
tom in  many  cases  and  may  precede  all  others  (Westphal's  symptom). 
This  feature  is  rarely  absent.  The  patient  should  sit  for  the  test  upon 
the  edge  of  a  table,  or  the  leg  may  be  supported  by  the  hand  of  the 
examiner  placed  under  the  knee,  and  his  attention  should  be  diverted  by 
having  him  grasp  the  sides  of  the  table  or  chair,  while  a  sharp  blow  is 
struck  upon  the  lower  border  of  the  patella.  The  other  reflexes  are 
usually  lost  during  the  progress  of  the  disease.  Ocular  symptoms  appear 
early  in  some  cases  and  late  in  others.  The  most  common  of  them  are  a 
gradual  loss  of  vision,  sometimes  terminating  in  blindness,  due  to  atro- 


POSTERIOR  SPINAL  SCLEROSIS  649 

phy  of  the  optic  nerve;  single  or  double  ptosis  (drooping- lids),  paralysis 
of  one  or  more  of  the  external  muscles  of  the  eye,  and  the  Argyll  Rob- 
ertson pupil,  in  which  the  iris  contracts  during  accommodation,  but  not 
to  light.    The  pupils  are  often  closely  contracted  (spinal  miosis). 

Trophic  and  vasomotor  symptoms  are  occasionally  observed  early, 
but  not,  as  a  rule,  until  the  ataxic  stage.  Difficulty  in  the  evacuation  of 
the  bladder  and  decrease  of  sexual  power  and  desire  are  sometimes  early 
manifestations ;  incontinence  of  urine  and  cystitis  may  appear  later. 

(2)  Ataxic  Stage. — The  typical  symptom  of  this  stage  is  the  loss  of 
the  muscle  sense.  This  is  usually  gradual,  and,  as  stated,  may  appear 
early  or  it  may  be  well  advanced  before  it  is  recognized.  In  it  the 
patient  loses  the  normal  sensation  in  the  feet,  as  already  described,  and 
he  cannot  recognize  the  position  of  his  hmbs  in  bed.  He  is  unable  to 
walk  steadily  in  the  dark,  to  stand  upon  one  foot,  or  with  his  feet  to- 
gether, when  his  eyes  are  closed  (Romberg's  symptom).  A  toppling 
forward  while  in  the  act  of  washing  the  face  is  highly  typical.  Inco-ordi- 
nation  of  movements  soon  develops,  and  the  characteristic  ataxic  gait  is 
produced.  The  patient  can  guide  the  movements  of  his  feet  only  through 
the  sense  of  sight.  He  walks  with  his  body  inclined  forward,  his  feet  wide 
apart,  and  usually  with  the  aid  of  a  cane.  The  feet  are  swung  outward 
and  forward  and  brought  down  flat  or  on  the  heel.  Inco-ordination  of  the 
arms  develops  later  in  most  cases,  occasionally  before  that  of  the  legs. 
The  patient  experiences  difficulty  in  all  delicate  movements.  If  asked  ta 
extend  the  arm  and  to  immediately  touch  the  tip  of  his  nose  with  the 
forefinger,  he  misses  the  mark  and  may  fail  to  touch  his  face.  The 
muscles  become  relaxed  and  the  joints  can  be  abnormally  extended;  the 
knees  sometimes  bow  backward,  yet  the  muscular  strength  is  retained. 

Sensory  Symptoms. — Li  addition  to  the  sensory  symptoms  referred  to 
under  the  Initial  Stage,  areas  of  hyperesthesia  or  of  anesthesia  may  be 
present,  particularly  in  the  lower  extremities,  but  sometimes  in  the  form, 
of  bands  about  the  thorax. 

The  affections  of  the  eye  sometimes  develop  in  this  stage,  but  it  is  a 
peculiar  fact  that  atrophy  of  the  optic  nerve  is  rarely  associated  with 
ataxia.  Deafness  may  develop,  but  the  sense  of  smell  is  seldom  affected. 
There  may  be  incontinence  of  urine  and  cystitis  in  this  stage,  as  stated, 
and  the  inflammation  may  extend  to  the  kidneys.  Obstinate  constipa- 
tion is  the  rule;  the  anal  sphincter  becomes  relaxed. 

Trophic  disturbances  are  common.  The  fulgurant  pains  may  be  ac- 
companied with  an  eruption  of  herpes,  edema  or  local  sweating.  The 
nails  become  atrophic  and  the  hair  falls.  A  perforating  ulcer  sometimes 
forms  in  the  foot,  back  of  the  big  toe  or  in  the  heel,  occasionally  in  the 
cheek,  and  a  round  ulcer  may  be  found  in  the  rectum.  The  joint  lesions 
most  frequently  affect  the  knees.  In  the  so-called  Charcot  joint,  the  con- 
ditions are  very  similar  to  those  of  arthritis  deformans,  but  suppuration 
sometimes  develops,  and  dislocation  or  spontaneous  fracture  may  occur. 
Extensive  effusion  sometimes  collects  about  the  joint  (hydrarthrosis) 
and  may  rupture  spontaneously.  Late  in  the  disease  the  muscles  un- 
dergo atrophy,  probably  as  a  result  of  degeneration  in  the  ventral  horns 
or  of  peripheral  neuritis.  Frankel  has  called  attention  to  the  ability  of 
the  patient  to  extend  his  legs  completely  when  they  are  at  a  right  angle 
to  the  body,  lying  upon  the  side  (hypotonia).    Cerebral  symptoms  are 


650  PRACTICE  OF  MEDICINE 

frequent :  hemiplegia  at  any  time ;  melancholia,  paralj^tic  dementia,  or 
paranoia,  at  a  late  period. 

3.  Paralytic  Stage. — This  stage  begins  when  the  patient  finally  be- 
comes unable  to  walk.  Absolute  helplessness  often  characterizes  the 
condition,  and  the  sphincters  are  often  paral_vzed.  The  patient  may 
linger  for  months  in  this  state,  often  blind  and  deaf,  until  death  super- 
venes from  exhaustion  or  some  intercurrent  disease. 

Diagnosis. — There  is  seldom  difficulty  in  the  diagnostication  of  a  well- 
marked  case.  The  loss  of  patellar  reflex,  the  inco-ordination,  the  loss  of 
muscular  sense,  the  crises,  and  the  Arg}dl  Robertson  pupil  are  all  pathog- 
nomonic.   Several  conditions  may,  however,  enter  into  consideration. 

Disease  of  the  ce7-e'benii7n  is  accompanied  with  inco-ordination,  nausea, 
and  vomiting,  but  there  are  also  headache  and  vertigo,  and  the  pain 
and  pupillary  reaction  are  absent.  Ataxic  paraplegia  \%  c\v3.x3s:ttx\ztA.\iY 
an  increase  of  the  patellar  reflex.  Multiple  neuritis  produces  hyperesthesia 
along  the  course  of  the  affected  nerves,  without  inco-ordination,  crises,  or 
■ocular  symptoms.  Poly7ieuritis  is  attended  with  a  steppage  gait,  without 
the  more  characteristic  symptoms  of  tabes.  Its  onset  and  course  are 
much  more  acute.  There  is  often  ataxia  in  cerebral  disease,  but  only  one 
limb  is  aff"ected,  as  a  rule.  General  paresis  is  sometimes  accompanied  by 
the  symptoms  of  locomotor  ataxia  or  it  may  develop  late  in  the  history 
of  the  latter  disease;  under  such  circumstances  a  diagnosis  may  be 
difficult.  Recurrent  attacks  of  visceral  neuralgia  are  often  an  initial 
manifestation  of  this  disease,  and  its  absence  can  be  determined  only 
when,  after  careful  study  of  the  case,  all  other  s3^mptoms  are  found  to  be 
absent.  In  a  syphilitic  subject  a  conclusion  should  not  be  too  hastily 
arrived  at. 

Prognosis. — Recovery  is  impossible  after  the  disease  has  become  fully 
established  and  the  cord  sclerotic.  Long  periods  of  quiescence  may  occur, 
however,  and  a  slow  progress  of  fifteen  or  twenty  years  is  possible. 

Treatment. — The  first  essential  is  a  removal  of  all  causal  influences,  as 
alcoholism,  sexual  or  other  excesses,  and  the  patient  must  avoid  fatigue. 
Since  the  mind  remains  unaffected  until  a  very  late  stage,  he  may  con- 
tinue his  occupation  if  a  professional  or  business  man.  It  is  well  in  all 
cases  to  administer  mercury  and  potassium  iodid  for  a  period  of  several 
months,  as  the  disease  is  often  arrested  in  this  manner,  for  a  time  at 
least.  Gold  and  sodium  chlorid  and  silver  nitrate  are  occasionally  em- 
ployed, but  they  are  of  doubtful  utility,  and  the  danger  of  argyria  ex- 
ceeds any  possible  gain  to  be  obtained  from  the  silver  salt.  Ergot, 
calabar  bean,  arsenic,  strychnin,  and  other  drugs  are  recommended  by 
some  writers. 

Local  applications,  ice-bags,  cold  douches,  blisters,  and  the  cautery, 
are  recommended,  but  they  are  to  be  thought  of  only  in  cases  presenting 
an  unusually  acute  onset,  and  they,  as  a  rule,  unnecessarily  confine  the 
patient  to  bed.  Galvanism  of  the  spine  is  extolled  by  Gray  and  others, 
but  it  is  not  always  well  borne. 

The  suspension  treatment  is  now  seldom  resorted  to.  It  consists  in 
suspending  the  patient  by  the  arms  and  head  by  means  of  a  suspension 
apparatus  for  from  30  seconds  to  three  minutes  twice  a  week.  The  ob- 
ject is  to  make  traction  upon  the  cord.  Many  patients  are  much  relieved 
for  a  time,  but  the  method  can  exert  no  influence  upon  the  sclerotic  tissue. 


PRIMARY  LATERAL  SCLEROSIS  651 

The  crises  can  be  overcome  in  some  cases  only  by  the  administration 
•of  an  opiate,  which  is  to  be  avoided  as  long  as  possible.  Sodium  sali- 
cylate, phenacetin,  acetanilid,  or  canabis  indica  should  be  employed ;  and 
when  they  fail,  codein  may  be  given  in  doses  of  gr.  %  (0.0 1).  Regula- 
tion of  the  diet  and  relief  of  constipation  often  diminish  the  frequency  of 
the  gastric  crises.  The  application  of  the  faradic  brush  is  sometimes  of 
benefit.  When  the  crises  are  accompanied  with  high  arterial  tension,  they 
^re  sometimes  relieved  by  continued  administration  of  glonoin.  Fran- 
kel's  method  of  re-educating  the  patient  in  co-ordinated  movements  yields 
good  results  in  some  cases  in  the  hands  of  a  skillful  instructor. 

In  the  paralytic  stage  the  utmost  care  is  necessary  for  the  avoidance 
of  bedsores  and  excoriations.  Catheterization,  vesical  irrigation,  and 
liigh  rectal  injections  are  often  beneficial. 


PRIMARY  LATERAL  SCLEROSIS. 

SPASTIC  PARALYSIS  OF  ADULTS,  SPASTIC  SPINAL  PARALYSIS. 

Definition.— K  gradually  increasing  paresis  with  spasm  of  the  muscles, 
without  atrophy  or  sensory  disturbance,  usually  beginning  in  the  lower 
extremities  and  probably  due  to  degeneration  of  the  pyramidal  tracts. 

Eiiology. — The  disease  is  most  frequent  in  middle-aged  men  with  syphi- 
litic taint. 

Symptoms.— The  patient  complains  of  fatigue  and  stiffness  of  the  legs, 
sometimes  of  pain,  and  later  his  legs  become  rigid  when  he  stands.  He 
walks  stiffly  upon  the  balls  of  the  feet  without  touching  the  heels  and 
without  bending  the  knees,  taking  short,  quick  steps  and,  in  an  advanced 
stage,  crossing  one  leg  in  front  of  the  other.  The  legs  can  be  passively 
ilexed  slowly  to  any  angle,  and  remain  there,  but  an  attempt  at  sudden 
flexion  is  resisted.  In  the  worst  cases  the  legs  are  drawn  closely  together 
"by  the  adductors.  x\ll  the  reflexes  of  the  lower  extremity  are  usually 
much  increased.  The  strength  of  the  muscles  is  retained  until  late,  as  a 
rule.  In  an  advanced  stage,  the  arms  often  become  similarly  affected, 
rarely  simultaneously  with  the  legs.  Ocular  symptoms  are  rare.  The 
sphincters  are  involved  late  in  some  cases.  The  plantar  reflex  is  so 
altered,  in  some  cases,  that  slight  irritation  of  the  sole  causes  exten- 
sion of  only  the  great  toe  (Babinski  sign  of  organic  disease  of  the 
pyramidal  tract).  The  course  of  the  disease  is  exceedingly  chronic,  but 
it  may  not  interfere  materially  with  the  general  health  for  many  years. 

Diagnosis. — In  the  absence  of  a  definite  pathology,  the  diagnosis  is 
necessarily  difficult.  Tumors,  hemorrhage,  vertebral  caries,  transverse 
myelitis,  and  hysteria  can  sometimes  be  excluded  with  great  difficulty. 
General  paresis  sometimes  begins  with  the  symptoms  of  this  affection. 

Prognosis. — Recovery  is  not  to  be  hoped  for. 

Treatment. — Potassium  iodid  and  mercury  should  be  administered. 
Ergot  may  also  be  employed.  Hot  baths  and  massage  may  be  of 
benefit. 

Hereditary  Spastic  Paraplegia  (Hereditary  Spastic  Spinal  Paralysis). 
— (See  also  Cerebral  Paralyses  of  Childhood.)  Two  groups  of  cases  are 
recognized.  One  develops  in  infants  or  young  children  and  is  accom- 
panied with  cerebral  disturbances,  as  epileptic  seizures  or  mental  dullness. 


652  PRACTICE  OF  MEDICINE 

Erb  referred  the  symptoms  to  degeneration  of  the  lower  part  of  the 
pyramidal  tract.  In  the  other  group  the  disease  develops  between  the 
2oth  and  30th  years  as  a  spastic  condition  of  the  legs,  short  of  paralysis, 
progresses  slowly  for  years,  and  finally  affects  the  arms.  At  the  end  the 
paralysis  becomes  complete  and  may  slightly  involve  the  bladder. 

Amaurotic  Family  Idiocy. — This  is  another  form  of  infantile  paraly- 
sis occurring  in  families  and  characterized  by  mental  disturbances  which 
deepen  into  idiocy;  paresis  ending  in  paralysis,  partial  and  later  total 
blindness,  with  normal,  increased,  or  decreased  tendon  reflexes. 

Secondary  Spastic  Paralysis. — This  term  is  applied  to  spastic  paralysis 
developing  in  the  course  of  any  disease  affecting  the  pyramidal  tract,  as 
in  transverse,  compression,  or  chronic  myelitis,  or  in  multiple  sclerosis. 
The  condition  is  recognized  by  the  rigidity  and  the  exaggeration  of  the 
reflexes. 

Erb's  Syphilitic  Spastic  Spinal  Paralysis  (Toxic  Spastic  Spinal  Pa- 
ralysis— Osier). — This  is  regarded  by  Erb  as  a  form  of  transverse  myelitis. 
It  is  characterized  by  muscular  rigidity,  exaggeration  of  the  deep  re- 
flexes, sometimes  with  paresthesia  and  the  girdle  sensation,  disturbance 
of  the  sphincters,  and  impotence. 

Hysterical  Spastic  Paraplegia. — This  is  characterized  by  partial  loss  of 
power,  moderate  rigidity,  atrophy,  increased  reflexes,  and  in  some  cases 
a  spurious  ankle  clonus  (Gowers). 

ATAXIC   PARAPLEGIA   (GOWERS). 

Definition. — Sclerosis  of  the  posterior  and  lateral  columns,  sometimes 
annular  or  diffuse  and  not  confined  to  the  pyramidal  tracts. 

Etiology. — The  disease  usually  occurs  in  men  of  middle  age  without 
syphilitic  history,  sometimes  after  injury  or  exposure  to  cold. 

Morbid  Anatomy. — The  sclerosis  in  many  cases  is  confined  to  the  ter- 
minal branches  of  the  dorsal  spinal  artery  (Marie). 

Symptoms. — The  legs  feel  tired  and  the  gait  is  unsteady  and  stamping. 
There  is  no  pain  or  sensory  disturbance.  The  inco-ordination  and  rigid- 
ity increase,  and  the  arms  finally  become  involved.  The  reflexes  become 
exaggerated.  The  sphincters  are  affected  late.  Eye  symptoms  are  rare. 
The  diagnosis  is  based  upon  the  inco-ordination  without  loss  of  reflexes, 
ocular  or  sensory  changes. 


HEREDITARY  ATAXIA. 

FRIEDREICH'S    ATAXIA,    HEREDITARY    TOXIC     PARAPLEGIA,    POSTEROLAT- 
ERAL SCLEROSIS. 

Definition. — A  combined  degeneration  and  sclerosis  of  the  posterior 
and  lateral  columns  of  the  cord  and  posterior  nerve-roots,  producing 
ataxia  and  paraplegia. 

Etiology. — The  disease  occurs  in  families,  affecting,  as  a  rule,  several 
brothers  and  sisters,  but  it  is  not  always  hereditary.  It  generally  de- 
velops in  childhood  or  early  life  and  more  commonly  in  males.  Syphilis 
is  not  a  constant  factor  in  its  production. 


SYRINGOMELIA  653 

Morbid  Anaiomy. — The  lesions  are  a  combination  of  those  belonging- 
to  locomotor  ataxia  and  those  of  the  ataxic  paraplegia  of  Gowers. 
The  sclerosis  is  thought  by  some  writers  to  be  neuroglear  and  different 
from  other  spinal  scleroses.  The  lesions  are  generally  found  in  the  cer- 
vical and  lumbar  regions. 

Symptoms. — The  inco-ordination  begins  in  the  legs,  and  the  gait  is 
more  irregular  and  swaying  than  that  of  locomotor  ataxia.  The  arms 
are  more  pronouncedly  affected  than  in  the  latter  disease.  There  is 
often  a  swaying  movement  of  the  arms  and  head  (static  ataxia)  when 
the  body  is  at  rest;  sometimes  the  movements  are  more  like  those  of 
chorea.  The  patient  is  generally  unable  to  walk.  The  paraplegia  is 
rather  a  paresis  than  a  paralysis.  Late  in  the  disease,  contractures, 
scoliosis,  and  talipes  equinus,with  dorsal  flexion  of  the  great  toe,  develop. 
Hyperesthesia  and  retardation  of  sensation  are  occasionally  present, 
but,  as  a  rule,  there  is  no  sensory  disturbance.  The  deep  reflexes  are 
early  lost,  but  the  cutaneous  and  pupillary  remain  normal.  Nystagmus 
is  a  constant  and  characteristic  symptom.  The  speech  is  slow  and  scan- 
ning.   The  mind  remains  normal  until  late. 

Diagnosis. — Ataxic  paraplegia  is  excluded  by  the  absence  of  the  knee- 
jerk,  ankle  clonus,  and  muscle  spasm.  Locomotor  ataxia  is  distinguished 
by  its  ocular  symptoms,  and  it  is  a  disease  of  later  life.  Disseminated 
sclerosis  is  characterized  by  greater  inco-ordination  of  the  arms  and  less 
of  the  legs.  He^-iditary  chorea  is  not  accompanied  with  nystagmus, 
loss  of  the  deep  reflexes,  scoliosis,  talipes,  or  flexion  of  the  toe. 

Prognosis. — There  is  no  possibility  of  recovery,  but  the  disease  is  not 
incompatible  with  many  years  of  life. 

Treatment. — This  is  the  same  as  that  of  locomotor  ataxia,  but  fewer 
cases  are  benefited  by  the  potassium  iodid.  Massage  and  other  methods 
for  the  prevention  of  contractures  should  be  employed. 

Cerebellar  Type. — Marie  and  others  have  described  a  type  of  the  dis- 
ease occurring  in  adults  and  due  to  atrophy  of  the  cerebellum.  The 
legs  become  rigid,  but  the  tendon  reflexes  are  retained.  Scoliosis  and 
talipes  are  absent. 

Toxic  Combined  Sclerosis. — A  combined  sclerosis  affecting  several  col- 
umns of  the  cord  is  sometimes  observed  after  poisoning  with  ergot  and 
in  pernicious  anemia,  pellagra,  and  some  of  the  chronic  wasting  diseases, 
probably  as  a  result  of  poisons  produced  in  the  body. 

Progressive  Interstitial  Hypertrophic  Neuritis  of  Infants.— This  is 
a  rare  family  disease  occurring  in  early  life,  described  by  Dejarine  and 
Sottas.  It  is  characterized  by  the  symptoms  of  locomotor  ataxia  com- 
bined with  those  of  progressive  muscular  atrophy,  including  the  face,  and 
hypertrophy  and  sclerosis  of  the  peripheral  nerves. 


SYRINGOMYELIA. 

Definition.— k  disease  of  the  spinal  cord  due  to  the  growth  of  glioma- 
tous  tissue  about  the  central  canal,  and  resulting  in  the  formation  of 
small  cavities. 

Efiofogy.— The  disease   is    an  infrequent  one,  usually  affecting   males 


654  PRACTICE  OF  MEDICINE 

from  the  fifteenth  to  the  thirtieth  year.  Nothing  is  known  of  the  excit- 
ing cause. 

Morbid  Anatomy. — Small  cavities  of  various  shapes  are  formed  around 
the  central  canal  resembling,  but  distinct  from,  hydromyelus.  The  cavity 
is  usually  situated  in  the  dorsal  region,  sometimes  in  the  cervical,  and 
may  extend  the  entire  length  of  the  cord.  It  may  involve  only  one 
dorsal  cornu.  The  morbid  process  is  a  gliosis,  a  growth  of  embryonic 
neuroglear  tissue,  with  subsequent  degeneration  or  hemorrhage  and  cav- 
ity formation. 

Symptoms. — The  disease  begins  with  pains  in  the  arms  and  pares- 
thesia of  the  hands,  followed  by  anesthesia.  Its  progress  is  slow,  ex- 
tending to  the  trunk  and  then  to  the  lower  extremities.  A  spastic  con- 
dition develops,  with  exaggeration  of  the  reflexes  and  sometimes  the 
peculiar  symptoms  of  amyotrophic  lateral  sclerosis.  The  tactile  and 
muscular  senses  and  the  special  senses  are  retained,  but  the  perception 
of  pain  and  differences  of  temperature  is  lost.  Injury  often  results  from 
the  latter  condition.  Trophic  and  vasomotor  changes  are  common,  par- 
ticularly in  the  hands.  The  sphincters  are  not  involved  until  late,  when 
the  medulla  becomes  involved.  Scoliosis  may  be  produced.  Very  irregu- 
lar symptoms  are  sometimes  observed  which  have  been  described  bv 
Schlesinger  as  belonging  to  different  types  of  the  disease,  as  the  (a;) 
motor,  (i^)  sensory,  (r)  trophic,  or  (^)  tabetic  manifestations  predom- 
inate. 

Diagnosis.— The  differentiation  is  to  be  made  from  progressive  muscu- 
lar atrophy,  Morvan's  disease,  and  the  anesthesia  of  leprosy.  In  a 
typical  case  the  muscular  atrophy,  with  the  gait  of  amyotrophic  lateral 
sclerosis,  loss  of  pain  and  temperature  perception,  and  retention  of  the 
tactile  sense,  is  pathognomonic.  Morvan's  disease  is  further  distinguished 
by  its  unilateral  invasion  and  the  loss  of  tactile  sense ;  and  in  leprosy  the 
anesthesia  is  complete,  perineuritis  and  tubercles  are  present,  and  the 
bacillus  is  found. 

Prognosis. — The  course  of  the  disease  is  slow  and  interrupted  by  re- 
missions. It  may  thus  persist  for  fifteen  or  twenty  years,  but  is  ulti- 
mately fatal. 

The  treatment  is  purely  symptomatic. 

Morvan's  Disease. — This  is  the  trophic  type  of  syringomyelia  in  the 
classification  of  Schlesinger.  It  occurs  in  neurotic  subjects,  usually  young- 
adult  males,  sometimes  after  injury  or  exposure,  with  pains  and  atrophy 
of  the  hands  and  arms,  followed  by  anesthesia,  analgesia,  and  whitlows, 
sometimes  with  necrosis  of  the  phalanges.  The  course  of  the  disease 
is  protracted. 


TUMORS  OF  THE  SPINAL  CORD. 

Tumors  of  almost  every  variety  may  be  found  in  the  cord  or  its 
membranes.  With  the  exception  of  congenital  lipomata,  they  usually 
occur  between  the  ages  of  30  and  50,  more  frequently  in  men.  Tuber- 
cular, syphilitic,  and  gliomatous  growths  are  the  most  common  within 
the  cord,  while  fibromata,  sarcomata,  syphilitic,  and  tubercular  growths 
generally  attack  the  dura.    Parasitic  cysts  are  occasionally  found  in  the 


MALFORMATIONS  OF  THE  SPINAL  CORD  655 

extradural  space.  The  probable  exciting  causes  are  trauma  and  expos- 
ure. The  tumor  generally  begins  in  the  meninges;  tumors  of  the  ver- 
tebra sometimes  extend  to  the  cord.  The  tumor  is  small,  and  is  usually 
situated  in  the  lower  cervical  or  in  the  dorsal  region.  The  symptoms 
are  a  result  of  hemorrhage  or  softening  and  degeneration  due  to  pres- 
sure; myelitis  is  occasionally  set  up. 

Symptoms. — There  are  often  no  local  symptoms,  in  the  absence  of 
vertebral  disease.  Pain,  referred  to  the  distribution  of  the  nerves  that 
are  involved  in  the  pressure,  is  the  most  constant  symptom,  which  is 
generally  accompanied  with  disturbed  sensation,  at  first  unilateral,  but 
becoming  bilateral  with  the  increasing  growth  of  the  tumor.  Muscle 
rigidity  and  contractures  develop,  the  reflexes  are  increased,  and  paraly- 
sis follows,  with  such  trophic  affections  as  bedsores.  Sometimes  a  dif- 
ferent picture  is  presented,  with  loss  of  reflexes,  girdle  sensation,  pares- 
thesia, hyperesthesia,  or  anesthesia  in  different  areas,  spasm  of  the  mus- 
cles, and  finally  paralysis.  The  anesthetic  areas  are  sometimes  painful. 
The  diagnosis  is  generally  based  upon  the  character  of  the  disturbances 
in  the  nerve-roots  from  the  affected  region  and  the  gradual  paralysis, 
but  in  many  cases  the  manifestations  are  so  slight  or  so  vague  as  not 
to  be  diagnosticated  during  life.  In  caries  of  the  vertebrae,  the  pain 
is  not  usually  so  severe,  and  there  are  local  tenderness  and  swelling 
or  angular  curvature  (kyphosis).  Cervical  meningitis  yields  symptoms 
identical  with  tumor,  but  its  progress  is  more  rapid,  as  a  rule.  Trans- 
verse myelitis  has  also  a  more  rapid  course,  and  is  further  distinguish- 
able by  the  different  order  and  location  of  the  pain  and  other  symptoms. 

The  prognosis  is  unfavorable,  except  in  early  recognized  syphilitic 
cases.    The  duration  seldom  exceeds  three  years. 

Treatment. — Potassium  iodid  should  be  given  in  large  doses  when 
there  is  a  probability  of  syphilis.  In  other  cases  the  treatment  is  symp- 
tomatic, unless  surgical  measures  can  be  resorted  to. 


MALFORMATIONS  OF  THE  SPINAL  CORD. 

Spina  Bifida  (Meningocele,  Myelocele,  Hydrorrhachis). — This  is  a  con- 
genital affection,  chiefly  of  surgical  interest,  due  to  imperfect  closure  of 
the  spinal  canal.  A  fluctuating  tumor  is  formed  beneath  the  skin, 
which  contains  a  portion  of  the  dura  and  arachnoid  and  cerebrospinal 
fluid.  The  tumor,  usually  situated  over  the  lumbar  or  sacral  region, 
varies  in  diameter  from  one  to  five  inches.  The  cord  may  be  normal  or 
atrophic,  and  the  dilated  central  canal  sometimes  communicates  with 
the  cyst  cavity.  Various  pressure  symptoms  are  occasionally  produced, 
as  talipes  and  perforating  ulcer  of  the  foot.  Suppuration  may  de- 
velop in  the  sac,  or  rupture  may  occur,  with  immediately  fatal  result. 
Pressure  upon  the  sac  sometimes  distends  the  fontanels  and  may  pro- 
duce dyspnea  and  coma.  The  condition  usually  goes  from  bad  to  worse, 
but  the  patient  occasionally  recovers  spontaneously  or  through  oper- 
ative measures. 

Lesions  of  the  Conus  Medullaris  and  Cauda  Equina.— Injury,  disease, 
or  tumor  situated  below  the  second  lumbar  vertebra  may  produce  paraly- 
sis in  groups  of  muscles  or  areas  of  anesthesia,  loss  of  sphincter  control,. 


656  PRACTICE  OF  MEDICINE 

and  disturbance  of  sexual  function  through  pressure  upon  the  lumbar 
nerve-roots.  When  the  cauda  equina  alone  is  affected,  the  loss  of  sphinc- 
ter power  may  be  the  only  symptom. 


DISEASES  OF  THE  BRAIN  AND    ITS    MENINGES. 
DISEASES  OF  THE  MENINGES. 

EXTERNAL  PACHYMENINGITIS. 

Definition. — An  inflammation  of  the  external  layer  of  the  dura  mater 
of  the  brain. 

Etiology. — The  most  common  cause  is  injury,  especially  fracture  of  the 
skull,  caries,  or  inflammation  extending  from  without,  chiefly  from  the 
middle  ear,  frontal,  or  ethmoid  sinus.  Erysipelas  is  occasionally  re- 
sponsible for  an  acute  attack;  syphilis  is  a  common  factor  in  the  more 
chronic  cases. 

Morbid  Anatomy. — The  dura  is  thickened,  hyperemic,  edematous,  and 
opaque ;  it  may  be  detached  and  separated  by  an  accumulation  of  blood 
or  exceptionally  by  pus,  but  it  is  more  commonly  bound  down  by  firm 
connective  tissue.  Laminge  of  bone  are  sometimes  formed  in  it  in  chronic 
cases. 

Symptoms. — There  are  no  typical  manifestations.  Headache  and  lo- 
calized tenderness  are  common  to  this  and  many  other  affections.  Con- 
vulsions or  local  paralyses,  usually  of  a  mild  type,  are  sometimes  ob- 
served as  a  result  of  pressure.  In  a  large  group  of  cases,  especially 
in  the  insane,  the  disease  is  discovered  only  upon  autopsy. 

Treatment. — Medicinal  treatment  is  limited  to  syphilitic  cases,  in  which 
the  usual  remedies  should  be  employed.  An  early  resort  to  the  trephine 
is  indicated  in  most  nonsyphilitic  cases,  especially  when  there  is  evi- 
dence of  suppuration.  Counter-irritation  with  the  cautery  has  been  rec- 
ommended. 

INTERNAL   PACHYMENINGITIS. 

This  is  an  infrequent  aff'ection  occurring  as  a  pseudomembranous,  puru- 
lent, or  hemorrhagic  inflammation,  of  which  the  hemorrhagic  is  the  most 
common. 

Etiology. — The  aff'ection  is  met  with  chiefly  in  advanced  life,  occasion- 
ally in  children.  It  may  occur,  however,  in  chronic  tuberculosis,  syphilis, 
pernicious  anemia,  leukemia,  valvular  disease  of  the  heart,  or  other  con- 
ditions leading  to  degeneration  of  the  blood-vessels. 

Morbid  Anatomy. — One  or  more  punctate,  rarely  profuse  hemorrhages 
occur,  as  a  result  of  which  an  accumulation  of  blood  of  variable  quan- 
tity is  formed  between  the  dura  and  arachnoid.  The  clot  becomes  or- 
ganized to  some  extent.  It  is  usually  situated  beneath  the  parietal 
bone,  and  the  condition  is  sometimes  bilateral.  A  hematoma  is  formed 
in  the  more  extensive  cases. 

Symptoms. — In  many  cases  these  are  absent.  Pressure  symptoms  are 
sometimes  produced,  however,  and,  from  the  situation  of  the  aff'ection 
over  the  cortical  centers,  monoplegia  or  hemiplegia  may  result.  Apha- 
sia may  be  produced.     \^Taen  the  hemorrhage  is  extensive,  convulsions 


DISEASES  OF  THE  MENINGES  657 

or  fatal  coma  may  be  induced.  In  another  group  of  cases,  recurrent 
symptoms,  not  unlike  those  of  brain  tumor,  may  exist  for  many  years. 
Spontaneous  recovery  has  been  noted  in  a  few  instances.  The  treat- 
ment is  the  same  as  that  for  external  pachymeningitis. 

LEPTOMENINGITIS. 

Definition. — An  inflammation  of  the  pia  and  arachnoid  membranes  of 
the  brain. 

Etiology. — Inflammation  of  the  meninges  in  acute  cerebrospinal  men- 
ingitis, and  that  due  to  tuberculosis  or  syphilis,  are  not  included  under 
this  heading,  but  are  considered  elsewhere. 

The  disease  under  consideration  occurs,  as  a  rule,  in  the  third  and 
fourth  decade  of  life,  occasionally  in  childhood,  and  somewhat  more 
frequently  in  males.  («)  It  may  arise  from  secondary  infection  through 
the  bacilli  or  toxins  of  such  diseases  as  typhoid  fever,  influenza,  the 
acute  exanthemata,  rheumatism,  septic  pneumonia,  or  chronic  nephritis. 
The  pneumococcus  or  micrococcus  lanceolatus  is  found  in  most  of  these 
cases,  independently  of  pneumonia.  The  typhoid  bacillus  and  the  bacillus 
coli  communis  have  been  found.  (^)  Another  group  of  cases  owes  its 
origin  to  extension  of  the  inflammation  from  the  middle  ear,  wounds, 
fractures,  or  caries  of  the  skull,  in  which  staphylococci  or  streptococci 
are  usually  present.  Or  the  disease  may  arise  from  abscess  of  the  brain, 
thrombosis  of  the  sinuses,  suppurative  inflammation  of  the  nose,  frontal 
or  ethmoid  sinuses,  or  to  erysipelas. 

Morbid  Anatomy. — The  lesions  may  be  limited  to  a  small,  circum- 
scribed area,  or  they  may  extend  over  the  entire  brain  and  cord.  They 
may  be  limited  to  the  ventricles,  particularly  in  children.  When  due  to 
otitis,  the  disease  is  usually  unilateral;  due  to  pneumonia  or  ulcerative 
endocarditis,  it  is  bilateral  and  generally  confined  to  the  cortex.  In 
nephritis  and  cachectic  conditions  it  is  ordinarily  confined  to  the  base. 
The  inflammation  becomes  suppurative  almost  from  the  beginning. 
(Consult  also  the  paragraphs  on  the  Morbid  Anatomy  of  Cerebrospinal 
Meningitis,  p.  in,  and  Tubercular  Meningitis,  p.  179.) 

Symptoms. — Although  a  more  or  less  typical  train  of  symptoms 
is  common  to  nearly  all  cases,  there  are  often  no  peculiar  manifesta- 
tions by  which  the  exact  character  or  location  of  the  lesions  can  be 
diagnosticated.  In  a  majority  of  cases  the  features  are  the  same  as 
those  described  under  Cerebrospinal  or  Tubercular  Meningitis.  It  should 
be  borne  in  mind  also  that  the  supervention  of  headache,  photophobia, 
retraction  of  the  head,  possibly  with  vomiting,  constipation,  and  in- 
crease of  temperature  in  the  course  of  typhoid  fever  or  other  acute 
infection,  may  be  due  to  hyperemia  of  the  meninges,  without  actual  in- 
flammation. W^en,  however,  these  symptoms  persist,  and  especially 
if  convulsions  occur,  the  pulse  becomes  slow,  the  vision  obscure,  the 
hearing  impaired,  and,  when  hyperesthesia  develops,  the  face  assumes 
a  pained  expression,  and  opisthotonos  becomes  pronounced,  there  is  no 
longer  doubt  of  the  presence  of  meningitis.  These  symptoms  often  de- 
velop gradually,  and  the  diagnosis  may  be  in  doubt  for  several  days. 
In  the  early  suppurative  cases  there  are  often  chills,  irregular  fever, 
sweating,  with  projectile  vomiting,  and  the  pulse  may  be  accelerated 
42 


658  PRACTICE  OF  MEDICINE 

instead  of  slow.  The  slow  pulse,  with  fever,  is  more  significant  of  this 
disease.  Rigidity  and  twitching  or  spasm  of  the  muscles,  sometimes 
unilateral,  are  frequently  observed.  Incontinence  of  urine  and  feces  often 
develops  toward  the  close. 

Basilar  meningitis  is  characterized  more  especially  by  pressure  symp- 
toms due  to  involvement  of  the  nerve-trunks  within  the  cranium.  Stra- 
bismus, ptosis,  slight  facial  paralysis,  anesthesia,  and  throphic  disturb- 
ances due  to  involvement  of  the  fifth  nerve  are  common  symptoms. 
The  pupils,  at  first  small,  become  dilated  and  often  unequal.  Optic  neu- 
ritis, with  deepening  blindness,  is  not  uncommon,  and  the  respiration 
often  becomes  irregular.  The  reflexes  may  be  exaggerated  in  the  begin- 
ning, and  lost  at  a  later  stage. 

Diagnosis. — The  differentiation  from  acute  cerebrospinal  meningitis 
may  be  difficult,  but  this  can  generally  be  excluded  by  the  absence  of 
an  epidemic,  and  the  primary  development  of  symptoms  on  the  part  of 
the  spinal  cord,  as  pain  and  tenderness,  with  retraction  of  the  neck  and 
rigidity  or  contractures  of  the  extremities.  The  differential  diagnosis 
between  meningitis  and  other  affections  is  considered  under  Cerebro- 
spinal Meningitis  and  Tubercular  Meningitis. 

Prognosis. — Acute  suppurative  cases  usually  terminate  fatally,  but  sur- 
prising exceptions  are  occasionally  observed.  In  cases  due  to  secondary 
infection,  especially  when  they  develop  near  the  natural  termination 
of  the  disease,  the  outlook  is  more  hopeful,  but  the  disease  is  always 
a  grave  one,  and  death  is  often  preferable  to  the  blind,  paralytic,  and 
frequently  imbecile  condition  in  which  the  patient  is  left  after  recovery. 

Treatment. — All  the  measures  employed  in  the  treatment  of  acute 
cerebrospinal  meningitis  are  applicable  in  acute  cases.  The  patient  must 
be  given  complete  rest  in  a  quiet  room.  Ice-bags  should  be  applied  to 
the  head,  and  to  the  spine  when  the  cord  is  involved.  Thorough  ex- 
amination should  be  made  in  cases  of  obscure  origin  in  order  to  deter- 
mine the  cause,  and,  this  done,  the  propriety  of  attempting  relief  through 
surgical  measures  should  be  considered.  The  assistance  of  a  specialist 
is  generally  advisable.  Counter-irritation  by  means  of  the  cautery  lightly 
applied  to  the  back  of  the  neck  is  often  of  benefit,  and  the  barbarous 
seton  of  fifty  years  ago  was  often  followed  by  prompt  remission  of 
symptoms.  Lumbar  puncture  has  yielded  good  results  in  some  cases. 
The  bromids  should  be  administered  freely ;  morphin  is  sometimes  neces- 
sary for  the  relief  of  pain.  Potassium  or  ferric  iodid  is  of  benefit  during 
convalescence.  The  diet  should  be  nutritious  and  for  the  most  part  liquid. 
The  action  of  the  bowels  must  generally  be  regulated  with  laxatives. 

AFFECTIONS  OF   THE    BLOOD-VESSELS    AND   CIRCULA- 
TION OF   THE  BRAIN. 

Endarteritis  and  Arteriosclerosis.— Degenerative  changes  are  exceed- 
ingly common  in  the  blood-vessels  of  the  brain.  The  process  is  the  same 
as  that  described  under  the  heading  Arteriosclerosis  in  the  chapter  on 
Diseases  of  the  Circulatory  System.  It  may  be  localized  or  general, 
and  may  result  in  moderate  thickening  of  the  intima  or  a  complete 
obliteration  of  thelumen  of  the  vessel  (endarteritis  obliterans).  Atherom- 
atous patches  are  frequently  produced,  and  a  further  result  in  many 


AFFECTIONS  OF  THE  BLOOD-VESSELS  659 

cases  is  the  formation  of  miliary  aneurisms.  Syphilis  is  an  important 
etiological  factor,  and  a  great  majority  of  the  cases  not  so  produced 
occur  in  advanced  life.  Nodular  periarteritis  is  peculiar  to  syphilitic 
cases. 

Aneurism  of  the  Cerebral  Arteries.— Aneurisms,  other  than  miliary, 
which  are  considered  under  the  head  of  Cerebral  Hemorrhage,  are  occa- 
sionally met  with,  chiefly  upon  the  outer  surface  of  the  brain,  and,  as 
a  rule,  in  middle-aged  men.  They  result  from  endarteritis  or  embolism 
and  they  are  sometimes  associated  with  endocarditis,  since  it  is  the  most 
frequent  cause  of  embolism.  The  left  middle  cerebral  artery  is  most 
frequently  affected,  then  the  basilar  or  internal  carotid  and  the  commu- 
nicating arteries.  The  aneurism  is  generally  saccular,  occasionally  ses- 
sile, seldom  fusiform,  and  rarely  exceeds  a  half-inch  in  diameter.  Its 
structure  is  the  same  as  that  of  aneurisms  in  other  locations.  They 
erode  the  overlying  bone,  produce  moderate  compression  of  the  brain 
substance,  and  not  infrequently  rupture. 

Symptoms. — A  constant  headache  is  the  most  important  feature. 
This  is  aggravated  by  anything  which  increases  the  blood-pressure, 
as  exertion,  straining,  or  stooping.  There  is  usually  a  throbbing  sen- 
sation, and  the  patient  may  hear  a  bruit  with  each  pulsation.  Vertigo, 
nausea,  and  vomiting  are  frequent  symptoms.  Manifestations  distinctive 
of  the  location  of  the  aneurism  are  seldom  present.  Rupture,  with  the 
production  of  apoplexy,  is  the  usual  termination. 

Diagnosis. — Aneurism  is  differentiated  from  other  tumors  of  the  brain 
chiefly  by  the  intensification  of  the  symptoms  upon  slight  increase  of 
the  circulation.  Optic  neuritis  favors  tumor,  endocarditis  aneurism. 
Pressure  symptoms  involving  the  nerve-roots  at  the  base  generally 
point  to  aneurism,  since  it  is  more  commonly  situated  in  that  region. 

Prognosis. — The  disease  terminates  fatally  by  rupture  in  most  cases 
within  a  few  weeks  after  the  development  of  pronounced  symptoms. 

THROMBOSIS  OF  THE  SINUSES  AND  VEINS. 

Thrombosis  may  arise  primarily  or  secondarily  through  extension  of 
inflammation  from  contiguous  parts. 

Primary  thrombosis  is  occasionally  encountered  in  infants  under  six 
months  of  age,  and  generally  in  connection  with  diarrhea.  Cowers  re- 
gards thrombosis  of  the  veins  as  a  frequent  cause  of  infantile  hemiplegia. 

The  so-called  autochthonous  sinus-thrombosis  is  met  with  in  cases 
of  anemia  and  chlorosis,  usually  in  connection  with  thrombosis  of  the 
veins  in  other  parts  of  the  body.  It  occurs  also  in  the  late  stages  of 
cancer,  tuberculosis,  and  other  chronic  wasting  disease  (marantic  throm- 
bosis). 

Secondary  thrombosis  is  a  more  frequent  affection.  It  usually  arises 
from  disease  of  the  internal  ear,  rhinitis,  meningitis,  tubercular  caries, 
or  fracture  of  the  skull,  compression  by  tumors,  erysipelas,  or  suppura- 
tive disease  in  the  tissues  outside  of  the  skull. 

Morbid  Anatomy.— (Sae  Thrombosis,  p.  15.) 

Symptoms. — These  are  by  no  means  uniform.  Many  cases  begin  with 
fever,  and  chills  follow,  often  preceded  by  a  constant  headache,  dizziness, 
and  vomiting.     The  patient  becomes  listless,  stupid,  and  finally  delir- 


66o  PRACTICE  OF  MEDICINE 

ious,  or  he  may  have  convulsions.  Hemiplegia  is  not  unusual,  and  other 
manifestations  arise  which  more  definitely  point  to  the  situation  of  the 
thrombus. 

Longitudinal  Sinus. — Thrombosis  of  the  longitudinal  sinus  is  occa- 
sionally discovered  at  autopsy  in  cases  presenting  no  symptoms.  Head- 
ache, epistaxis,  convulsions,  vomiting,  and  other  disturbances  may, 
however,  occur,  and  the  veins  of  the  face  and  head  may  be  distended 
and  the  side  of  the  head  edematous.  The  fontanels  are  .distended  in  an 
infant,  and  meningitis  may  develop  or  convulsions  and  coma  may  be  pro- 
duced. 

Lateral  Sinus. — \Mien  the  cause  is  suppuration  of  the  internal  ear, 
this  affection  becomes  aggravated  and  the  tissues  about  the  ear  become 
edematous.  The  external  jugular  vein  of  the  affected  side,  receiving  less 
blood  than  its  fellow,  is  more  rapidly  emptied  during  a  full  inspiration 
(Gerhard).  The  clot  may  extend  into  or  through  the  internal  jugular 
vein,  causing  it  to  become  indurated  and  sensitive  to  pressure.  Optic 
neuritis  and  nystagmus  may  develop,  and  in  rare  cases  there  is  hoarse- 
ness or  aphonia,  dysphagia,  and  spasm  of  the  muscles  of  the  neck. 

Cavernous  Sinus. — The  important  feature  of  this  location  is  obstruc- 
tion of  the  flow  of  blood  from  the  ophthalmic  vein,  causing  edema  of 
the  conjunctiva  and  eyelids  of  the  affected  side,  with  protrusion  of  the 
globe.  The  retina  becomes  edematous,  its  veins  distended  and  pulsat- 
ing. The  orbital  muscles  may  become  paretic,  with  the  production  of 
strabismus.  The  ophthalmic  branch  of  the  fifth  nerve  becomes  painful. 
Suppurative  panophthalmitis  may  develop.  In  secondary  thrombosis 
the  onset  is  often  sudden  and  the  symptoms  of  septicemia  may  be  pres- 
ent from  the  beginning,  along  with  others  to  some  extent  of  a  localiz- 
ing order. 

The  diagnosis  is  based  upon  the  peculiar  symptoms  of  localization, 
for  the  general  features  are  common  to  tumors,  abscess,  and  other  affec- 
tions. The  development  of  the  symptoms  described,  in  connection  with 
chlorosis  or  anemia,  is  highly  diagnostic  of  thrombosis. 

The  prognosis  is  grave  and  usually  extremely  unfavorable. 

The  treatment  is  surgical,  especially  in  cases  due  to  ear  disease;  or 
it  is  only  palliative. 

ANEMIA  OF  THE  BRAIN. 

The  brain  becomes  anemic  in  those  conditions  in  which  there  is  gen- 
eral anemia,  as  after  profuse  hemorrhages,  pernicious  anemia,  leukemia, 
or  inanition.  Anemia  of  the  brain  may  result  also  from  the  accumula- 
tion of  a  large  quantity  of  blood  in  certain  regions,  as  in  the  peritoneal 
cavity  after  tapping  for  ascites.  A  more  permanent  condition  results 
from  aortic  stenosis.  Sometimes  it  is  due  to  such  local  conditions  as 
obliterative  endarteritis,  the  pressure  of  tumors,  or  an  obliteration  of 
a  portion  of  the  circle  of  Willis,  accumulation  of  fluid  in  the  ventricles, 
the  anemia  involving  the  entire  brain  or  only  a  part  of  it. 

The  appearance  of  the  brain  after  death  is  typical.  The  smaller  ves- 
sels are  empt}-,  and  the  entire  brain  substance  is  moist  and  extremely 
pale.  Anemia  of  the  pia  mater  is  usually  associated  with  that  of  the 
brain. 


CEREBRAL  HEMORRHAGE  66 1 

Symptoms. — When  the  anemia  develops  acutely,  vertigo  or  syncope  is 
produced.  WTien  a  little  less  acute  there  is  roaring  in  the  ears,  flashes 
of  light  before  the  eyes,  the  sight  becomes  dim,  respiration  is  rapid, 
sometimes  nausea  and  vomiting  occur,  and  the  patient  may  become 
delirious. 

HYPEREMIA  OF  THE  BRAIN. 

Hyperemia  of  the  brain  may  be  active  or  passive.  Active  hyperemia 
probably  accompanies  any  marked  increase  of  the  general  circulation ; 
but  hyperemia  of  the  brain  is  a  condition  of  high  intravascular  ten- 
sion rather  than  an  increased  quantity  of  blood.  A  more  or  less  general 
active  hyperemia  occurs  in  all  inflammatory  conditions,  and  perhaps  in 
some  of  the  acute  iijfectious  diseases,  especially  those  accompanied  with 
restlessness,  insomnia,  delirium  or  other  cerebral  manifestations. 

Passive  hyperemia  is  induced  by  any  influence  which  fetards  the  re- 
turn of  blood  from  the  cerebrum,  as  in  general  venous  engorgement 
of  valvular  disease,  emphysema,  asthma,  and  sometimes  from  the  pres- 
sure of  tumors.  The  symptoms  of  hyperemia  are  not  uniform.  In- 
somnia, restlessness,  convulsions,  are  generally  attributed  to  active  hy- 
peremia, while  mental  dullness  and  coma  are  regarded  as  belonging  to 
passive  hyperemia. 

Treatment. — That  of  anemia  is  general,  consisting  in  the  administra- 
tion of  remedies  for  the  improvement  of  the  condition  of  the  blood,  re- 
lief of  inanition,  and  tonics  to  strengthen  the  circulation.  In  hyperemia 
an  effort  should  be  made  to  reach  the  cause.  Some  relief  is  aff'orded 
by  the  application  of  ice-bags  to  the  head,  and  the  administration  of 
full  doses  of  the  bromids,  or  1 5-drop  doses  of  hydrobromic  acid. 

EDEMA  OF  THE  BRAIN. 

This  occurs,  for  the  most  part,  in  atrophy  of  the  cerebral  convolu- 
tions, thrombosis  of  the  sinuses,  passive  hyperemia,  chronic  nephritis, 
occasionally  in  acute  alcoholism,  and  locally  in  the  vicinity  of  tumors 
and  abscesses  of  the  brain.  The  appearance  of  the  brain  is  similar  to 
that  of  anemia.  The  quantity  of  fluid  in  the  ventricles  and  tissues  is 
increased  and  there  is  general  pallor.  The  symptoms  are  not  clearly 
defined.  If  the  view  of  Leube  is  correct,  they  embrace  many  of  the 
cerebral  manifestations  of  uremia. 

Treatment. — An  effort  should  be  made  to  hasten  the  absorption  of 
fluid  by  catharsis,  diuresis,  and  diaphoresis.  The  treatment  must  be 
modified  to  a  great  extent,  however,  to  conform  to  the  causal  indica- 
tions. Digitalis  and  strychnin  should  be  employed  when  the  circulation 
is  feeble. 

CEREBRAL  HEMORRHAGE. 

APOPLEXY,  INTRACRANIAL  HEMORRHAGE,  "PARALYTIC  STROKE." 

Definition. — Hemorrhage  due  to  the  rupture  of  a  cerebral  blood- 
vessel. 

Etiology. — Cerebral  hemorrhage  occurs  most  frequently  in  individuals 


662  PRACTICE  OF  MEDICINE 

over  50  years  of  age.  It  is  occasionally  met  with,  however,  in  infants 
or  in  young  adult  or  middle  life.  In  the  latter  group  of  cases  it  is  gen- 
erally a  result  of  syphilitic  disease  of  the  arteries.  It  is  more  common 
in  men  than  in  women,  and  the  transmission  of  a  hereditary  tendency  is 
often  apparent,  particularly  in  gouty  families.  Individuals  with  habitu- 
ally high  arterial  tension,  whether  natural  or  the  result  of  alcoholic  or 
other  poisoning  of  the  blood,  are  doubtless  more  liable  to  apoplexy 
than  others,  but  there  is  no  type  of  stature  or  physique  by  which  such 
tendency  can  be  invariably  prognosticated. 

Predisposing  Causes. — Conditions  which  favor  a  degeneration  of  the 
blood,  with  the  production  of  endarteritis  or  arteriosclerosis,  and  par- 
ticularly the  production  of  miliary  aneurisms,  strongly  tend  to  the  de- 
velopment of  cerebral  hemorrhage.  Among  these  are  syphilis,  chronic 
alcoholism,  chronic  nephritis,  gout,  lead  and  other  metallic  poisons, 
anemia,  leukemia,  and  purpura  hemorrhagica. 

Excitijig  Causes. — Violent  muscular  effort,  nervous  excitement,  anger, 
fright,  and  intoxication  are  frequent  exciting  causes,  but  many  cases 
occur  independently  of  any  such  influences,  at  night  and  during  sleep. 
Engorgement  of  the  stomach  by  overeating  and  drinking,  perhaps  asso- 
ciated with  constipation,  often  precedes  an  attack. 

Morbid  Anatomy. — The  essential  lesion  in  a  majority  of  cases  is  a  rup- 
ture of  a  miliary  aneurism.  Next  most  frequent  is  the  rupture  of  a  ves- 
sel at  a  point  weakened  by  atheromatous  degeneration.  Either  of  these 
conditions  results  from  a  primary  hyalin  or  other  degeneration  of  the 
intima,  with  softening,  degeneration,  and  finally  distention  or  destruc- 
tion of  the  media ;  or  beginning  in  the  media  and  involving  the  intima. 
The  aneurism  which  has  ruptured  is  often  found  with  great  difficulty. 
It  is  most  frequently  situated  upon  a  branch  of  the  middle  cerebral 
artery,  especially  in  the  anterior  perforated  space,  but  any  of  the  cere- 
bral vessels  may  be  involved.  Secondary  changes  are  found  in  the  clots, 
and  the  nerve-fibers  that  have  been  subjected  to  pressure  become  sclero- 
tic or  otherwise  degenerated. 

Symptoms. — The  onset  is  usually  sudden,  often  in  the  midst  of  appar- 
ently good  health  and  without  premonitory  symptoms.  Such  prodromes 
as  headache,  vertigo,  thickness  of  speech,  or  numbness  and  tingling 
of  the  hand  are  observed  in  some  cases  for  a  few  hours,  possibly  for 
several  days  before  the  seizure.  Following  the  hemorrhage  the  symptoms 
may  be  divided  into  two  groups,  those  of  the  attack  (chiefly  reflex),  and 
later  or  localizing  symptoms. 

The  Seizure. — The  first  symptoms  are  in  great  measure  due  to  shock. 
The  patient  becomes  unconscious;  rarely  he  is  seized  with  a  convulsion. 
Occasionally  the  seizure  is  less  violent,  intense  headache  is  complained 
of,  there  are  vertigo  and  nausea,  vomiting,  and  psychical  disturbance; 
the  loss  of  consciousness  is  less  sudden,  and  the  paralysis  may  be  recog- 
nized before  coma  has  supervened.  The  coma  is  generally  profound. 
The  face  is  intensely  cyanotic,  or  it  may  have  an  ashen  hue.  The  respi- 
ration is  rapid,  full,  snoring,  and  often  stertorous.  Expiration  is  ac- 
companied with  dilatation  of  the  cheeks  and  puffing  of  the  lips.  The 
pulse  is  at  first  slow  and  full,  the  arterial  tension  may  be  relatively 
normal  or  greatly  increased.  When  the  tension  is  high,  the  pulse  often 
becomes  rapid.     The  pupils  are  usually  dilated,  often  unequal,  and  do 


CEREBRAL  HEMORRHAGE  663 

not  respond  to  light.  Conjugate  deviation  of  the  eyes  and  rotation  of 
the  head  toward  the  side  on  which  the  hemorrhage  has  occurred  are  often 
observed;  rarely  the  opposite  or  an  alternating  deviation.  The  tempera- 
ture is  subnormal  during  the  first  twenty-four  hours,  but  generally  rises 
to  100°  or  101°  F.  (37.8° — 39.3°  C.)  when  the  attack  is  not  imme- 
diately fatal.  The  skin  is  cool  and  moist.  This  reactionary  fever,  as 
it  is  called,  probably  due  to  changes  in  the  blood-clot  and  its  absorp- 
tion, may  last  a  week  or  two.  All  the  muscles,  even  the  sphincters, 
are  at  first  relaxed — those  which  are  paralyzed  to  a  more  profound 
degree  than  those  of  the  opposite  side.  The  face,  particularly  the 
mouth,  is  drawn  toward  the  sound  side.  All  the  reflexes  are  abolished 
for  a  time.  The  paralyzed  limbs  may  be  warmer  than  those  of  the  un- 
affected side. 

The  localizing  symptoms  vary  with  the  situation  of  the  lesion.  Since 
this  is,  in  a  majority  of  cases,  in  the  anterior  portion  of  the  internal 
capsule,  compression  of  the  motor  fibers  from  the  cortex  is  produced, 
and  hemiplegia  results.  The  hemiplegia  is  said  to  be  complete  when  the 
face,  arm,  and  leg  are  affected,  and  incomplete  when  either  of  these  parts 
escapes.  The  paralysis  affects  the  side  opposite  the  lesion  within  the 
brain,  owing  to  the  decussation  of  the  fibers.  In  those  instances  in  which 
the  fibers  do  not  decussate,  and  when  the  pressure  is  exerted  below  the 
point  of  decussation,  the  paralysis  involves  the  muscles  of  the  same  side. 
In  such  cases  the  lower  part  of  the  face  only  is  affected,  the  frontalis 
and  orbicularis  palpebrarum  escape.  The  hypoglossal  nerve  is  involved 
in  hemiplegia,  the  tongue  deviates  to  the  affected  side.  Aphasia  is  some- 
times present. 

The  completeness  of  the  paralysis  varies  in  different  cases  and  in  dif- 
ferent parts.  That  of  the  arm  is  usually  deeper  than  that  of  the  leg. 
•There  is  often  absolute  paralysis  of  the  arm  and  leg,  with  only  partial 
loss  of  power  in  the  face  muscles,  and  occasionally  the  leg  is  most  deeply 
affected.  A  paralysis  that  is  absolute  in  the  beginning  may  rapidly 
subside  into  a  partial  one.  Certain  muscles  frequently  escape.  Such 
trophic  changes  as  the  formation  of  vesicles  or  sloughing  are  sometimes 
developed  in  the  paralyzed  member.  Monoplegias  are  sometimes  observed, 
particularly  when  the  hemorrhage  is  in  the  motor  area  of  the  convo- 
lutions. This  is,  however,  an  infrequent  form  of  paralysis,  except  in  chil- 
dren, when  it  is  generally  accompanied  with  convulsions.  When  con- 
fined to  the  frontal  or  right  parietal  lobe,  focal  symptoms  may  be  absent. 
In  other  cases  localizing  symptoms  are  observed  in  the  following  rela- 
tions :  (</)  Hemorrhage  into  the  crus  causes  hemiplegia  of  the  oppo- 
site side  with  oculomotor  paralysis  of  the  same  side.  Qb^  Hemorrhage 
into  the  posterior  region  of  the  first  and  second  temporal  convolutions 
produces  word-deafness,  (r)  Hemorrhage  into  the  occipital  lobe,  the 
lingual  or  fusiform  lobule,  or  angular  gyrus  produces  blindness  in  one- 
half  of  the  field  of  vision  (hemianopia).  (^)  Hemorrhage  into  the  pons, 
if  slight,  causes  paralysis  of  one  side,  with  conjugate  deviation  of  the 
eyes  from  the  side  of  the  lesion.  When  in  the  lower  portion  of  the  pons, 
the  fifth  or  other  cerebral  nerve  may  be  involved,  producing  paralj-sis 
or  anesthesia  of  the  parts  supplied.  (^)  Hemorrhage  into  the  lateral 
ventricle  produces  paralysis  and  rigidity  of  the  opposite  side,  with  ster- 
torous   breathing   and    often    with  high  temperature  and  convulsions. 


664  PRACTICE  OF  MEDICINE 

(/)  Hemorrhage  into  the  cerebellum  causes  vertigo,  vomiting,  inco- 
ordination, severe  occipital  pain  and  sometimes  unconsciousness.  A 
staggering  gait,  once  thought  pathognomonic,  occurs  when  the  pe- 
duncles are  involved,  and  it  may  occur  in  hemorrhage  of  the  pons.  (^) 
Hemorrhage  into  the  medulla  causes  involvement  of  the  cranial  nerves. 
When  at  all  extensive,  it  is  usually  rapidly  fatal  from  embarrassment 
of  the  respiration  and  heart's  action.  Other  peculiarities  are  occasion- 
ally observed. 

The  course  of  the  disease  varies  with  the  extent  and  location  of  the 
hemorrhage.  After  a  slight  hemorrhage  the  symptoms  often  disappear 
rapidly ;  that  of  the  face  and  tongue  often  improves  within  a  few  days. 
Sometimes  the  leg  shows  the  most  rapid  recovery,  and  it  usually  pre- 
cedes that  of  the  arm.  The  muscles  of  the  shoulder  recover  before  those 
of  the  arm.  In  most  cases  the  leg  recovers  to  such  an  extent  that  the 
patient  becomes  able  to  walk  in  a  few  weeks,  although  he  may  never 
gain  full  use  of  the  limb,  and  the  arm  may  remain  limp  and  useless.  The 
early  improvement  may  prove  transitory,  and  be  followed  by  a  deepening 
of  the  paralysis,  with  or  without  recurrence  of  the  hemorrhage.  Post- 
paralytic rigidity  of  the  muscles  develops  in  most  cases  in  which  the 
paralysis  persists,  and  it  is  most  pronounced  in  the  arm  and  hand. 
The  contractures  are  often  painful  for  many  months,  strongly  flexing 
the  wrist  and  fingers.  Contractures  and  rigidity  sometimes  fail  to  de- 
velop, however,  particularly  in  cases  in  which  the  power  of  the  leg  has 
been  fully  restored.  Tremor  often  develops  late  in  the  paralyzed  mus- 
cles, or  there  may  be  a  choreic  movement  or  almost  rhythmical  sway- 
ing of  the  limbs  (athetosis).  The  reflexes  become  increased  in  the  later 
stages  of  the  disease.  Lesions  sometimes  develop  also  in  the  joints 
of  the  affected  members.  The  muscles  usually  atrophy  to  a  variable 
extent. 

Diagnosis.— The  recognition  of  a  hemiplegia  may  be  difficult  either  in 
cases  which  develop  suddenly  with  profound  coma,  or  in  those  in  which 
several  days  elapse  before  the  paralysis  becomes  complete.  In  the  former 
the  paralysis  can  generally  be  determined  by  raising  the  limbs  and  per- 
mitting them  to  drop.  The  paralyzed  member  always  falls  in  a  sudden, 
lifeless  manner,  while  slight  muscular  resistance  can  be  observed  in  the 
sound  side.  In  the  gradual  cases  the  diagnosis  must  be  established 
chiefly  by  the  history  of  the  case,  the  recognition  of  a  tendency  or  an 
exciting  cause,  and  the  presence  of  premonitory  symptoms.  A  slight 
rigidity  and  numbness  of  the  atTected  side  may  be  observed.  As  a  rule, 
however,  a  positive  diagnosis  must  be  deferred. 

Embolism  and  thrombosis  often  produce  symptoms  almost  identical 
with  those  of  hemorrhage,  and  a  diagnosis  may  not  be  possible.  The 
former  occurs,  as  a  rule,  in  younger  subjects,  the 'latter  in  older  ones, 
than  hemorrhage.  Fever  and  stertorous  breathing  are  absent  in  both. 
EmboHsm  can  be  traced  to  endocarditis.  The  pupils  are  usually  unaf- 
fected, convulsions  rarely  occur,  and  the  exciting  causes  are  different 
from  those  of  hemorrhage. 

Hemorrhage  of  the  pia  mater  may  cause  symptoms  of  cerebral  hemor- 
rhage, but  it  is  rarely  an  independent  affection. 

The  cotna  of  cerebral  hemorrhage  is  distinguished  from  that  of  uremia 
and  other  conditions  chiefly  by  the  history  of  the  case,  the  absence  of 


CEREBRAL  HEMORRHAGE  665 

albumin  or  sugar  from  the  urine,  and  the  recognition  of  rigidity  or  paral- 
ysis. The  pupils  are  usually  contracted  in  uremia,  and  the  eyes  do  not, 
as  a  rule,  deviate.  The  odor  of  alcohol  on  the  breath  may  be  of  value, 
but  it  is  often  dangerously  misleading.  The  possibility  of  fracture  of 
the  skull,  tumors  of  the  brain,  or  cerebral  syphilis  should  be  borne  in 
mind. 

Prognosis. — The  disease  is  always  a  grave  one.  Complete  recovery 
from  a  first  attack  is  possible;  incomplete  recovery  is  more  common. 
The  patient  may  live  many  years,  succumb  to  a  second  or  third 
attack  or  to  die  of  another  disease.  The  third  attack  is  generally, 
though  not  invariably,  fatal,  as  is  popularly  believed.  Much  depends 
upon  the  extent  and  location  of  the  lesion.  Hemorrhage  into  the  ven- 
tricles, or  rupturing  into  them,  is  usually  rapidly  fatal.  Hemorrhage 
upon  the  cortex  is  less  dangerous  than  at  the  base  or  within  the  cere- 
brum. High  fever,  delirium,  and  coma,  especially  increasing  coma  for 
48  hours,  are  exceedingly  unfavorable  symptoms.  The  improve- 
ment of  the  first  week  or  ten  days  may  be  deceptive.  The  late  contrac- 
tures and  tremor  are  permanent,  and  subject  to  little  or  no  improvement 
under  treatment. 

Treatment.  —The  patient  should  be  gotten  to  bed  with  as  little  delay 
as  possible.  He  should  be  placed  on  his  back  in  a  low  reclining  posture, 
with  the  head  high.  The  treatment  then  to  be  pursued  depends  upon  the 
condition  of  the  circulation.  When  the  arterial  tension  is  high,  it  should 
be  promptly  reduced.  Venesection  is  the  surest  and  best  means,  with- 
drawing from  10  to  20  ounces  of  blood.  It  must  not  be  practiced,  how- 
ever, in  a  case  of  low  arterial  tension  or  when  the  diagnosis  does  not 
clearly  exclude  embolism  and  thrombosis.  Nitroglycerin  should  be  ad- 
ministered when  bloodletting  is  objectionable.  It  should  be  given  in 
drop  doses  every  twenty  minutes  until  its  effect  becomes  apparent. 
WTien  the  heart's  action  is  rapid,  the  tincture  of  aconite  should  also 
be  administered,  but  its  action  must  be  watched,  and  the  administration 
stopped  as  soon  as  the  pulse  becomes  slower.  Next  in  importance  is  an 
early  evacuation  of  the  bowels.  Owing  to  the  condition  of  unconscious- 
ness, this  is  best  accomplished  by  placing  on  the  back  of  the  tongue 
gr.  iij  (0.20)  of  calomel,  or  gtt.  ij  of  croton  oil  in  emulsion  or  mixed 
with  butter  (Thompson).  If  there  is  muscular  twitching  or  other  pre- 
monition of  convulsions,  potassium  bromid  should  be  given  in  doses  of 
gr.  XX  (1.30),  repeated  twice  or  three  times  a  day.  An  ice-cap  should 
be  kept  constantly  upon  the  head.  The  patient  must  not  be  disturbed 
for  any  purpose,  but  his  position  should  be  occasionally  changed  to 
prevent  the  formation  of  bedsores.  He  should  also  be  provided  with 
an  air-cushion.  Catheterization  should  be  performed  during  the  coma. 
Alcoholic  stimulation  should  be  avoided.  Small  doses  of  strychnin  (gr. 
1-120  to  1-60)  may  be  employed  if  the  patient  becomes  weak  as  the 
acute  stage  subsides.  The  patient  must  not  be  permitted  to  sit  up  too 
soon,  and  the  ice-cap  should  be  kept  upon  the  head  for  several  days. 
As  the  paralysis  subsides,  the  affected  muscles  should  be  gently  rubbed 
for  ten  minutes  each  day  or  morning  and  evening,  and  after  the  second 
week  has  passed  they  should  be  treated  with  massage,  the  faradic  cur- 
rent, and  passive  motion,  as  these  measures  prevent,  to  some  extent,  the 
rigidity  and  contractures.     Potassium  iodid  is  regarded  by  some  phy- 


666  PRACTICE  OF  MEDICINE 

sicians  as  beneficial  in  the  removal  of  the  clot.  After  recovery,  the  pa- 
tient's life  should  be  a  quiet  one,  free  from  anxiety,  worry,  dissipation, 
and  other  forms  of  excess. 

EMBOLISM  AND  THROMBOSIS  OF  THE  BRAIN. 

Etiology. — The  embolus  is  generally  derived  from  the  mitral  or  aortic 
valve,  and  consists  of  fibrin  or  a  vegetation  formed  as  a  result  of  sim- 
ple or  malignant  endocarditis.  It  may  originate  from  a  thrombus  or 
from  the  interior  of  an  aneurism  of  the  aorta,  carotid,  or  other  vessel. 
Embolism  may  occur  at  any  age,  but  generally  between  lo  and  40, 
and  somewhat  more  frequently  in  women.  The  point  of  arrest  is  most 
frequently  the  middle  cerebral  artery,  sometimes  the  anterior  or  poste- 
rior cerebral  or  the  vertebral. 

Symptoms. — The  involvement  of  a  small  area  of  the  brain  in  either 
of  these  processes  may  give  rise  to  no  prominent  disturbance.  In  a  more 
extensive  embolism  the  patient  suddenly  becomes  unconscious  or  rarely 
falls  in  a  convulsion,  which  may  prove  fatal  within  a  few  hours,  or  it 
may  be  followed  by  paralysis  closely  resembling  that  of  cerebral  hemor- 
rhage. In  thrombosis  the  onset  is  generally  more  gradual,  beginning 
with  headache,  vertigo,  nausea,  vomiting,  paresthesia,  confusion  of  ideas, 
and  terminating  in  unconsciousness  and  paralysis.  The  conditions  are 
differentiated  from  cerebral  hemorrhage  under  that  disease, 

THE  CEREBRAL   PARALYSES  OF  CHILDHOOD. 

INFANTILE  PARALYSIS. 

The  principal  forms  of  paralysis  from  cerebral  lesions  met  with  in 
infancy  and  childhood  are  hemiplegia,  paraplegia,  and  diplegia,  occa- 
sionally also  quadruplegia. 

Etiology. — Most  cases  occur  during  the  first  two  years.  Some,  no  doubt, 
originate  in  intrauterine  life;  others  are  caused  by  injury  during  de- 
livery, as  by  the  forceps,  especially  in  unnatural  positions.  Falls,  blows, 
and  penetrating  wounds  are  responsible  for  some  cases,  and  others  fol- 
low more  or  less  immediately  upon  one  or  other  infectious  disease, 
especially  whooping-cough  and  those  attended  with  convulsions.  Para- 
plegia and  diplegia  are  generally  congenital  and  nearly  always  observed 
in  premature  infants. 

Morbid  Anatomy. — The  early  lesions  are  usually  those  of  embolism, 
thrombosis,  hemorrhage,  or  one  of  the  forms  of  encephalitis.  Later, 
there  is  sclerosis,  either  atrophic  or  hypertrophic,  limited  to  a  few  con- 
volutions, to  a  lobe,  or  involving  an  entire  hemisphere.  The  tissue  is 
extremely  hard.  The  membranes  are  adherent  over  the  affected  area, 
and  there  is  often  pachymeningitis  or  leptomeningitis.  Porencephalus, 
or  cyst-formation,  is  usually  observed.  One  or  many  cysts  are  formed 
in  the  brain  substance,  and  they  occasionally  communicate  with  the 
ventricles. 

Symptoms. — In  congenital  cases'  there  may  be  no  symptoms  except 
the  paralysis.  In  either  form  of  the  disease  developing  after  birth  there 
may   be   a  convulsion  or  sudden  unconsciousness,   with  fever  and  fol- 


SUPPURATIVE  ENCEPHALITIS  667 

lowed  by  paralysis.  The  paralysis  is  usually  most  profound  in  the  upper 
extremities ;  only  the  lower  portion  of  the  face  is  affected  in  most  cases. 
The  electrical  reaction  of  the  muscles  is  retained.  Recovery  may  occur 
during  the  course  of  a  month  or  several  months,  but  it  is  often  incom- 
plete. Rigidity,  tremor,  athetosis,  epilepsy,  aphasia,  or  an  arrest  or  re- 
tardation of  mental  development  is  usually  a  sequel  of  the  condition. 

Treatment. — The  treatment  of  the  initial  convulsions  is  the  same  as 
that  of  convulsions  from  other  causes,  by  the  administration  of  bro- 
mids,  or  chloroform  inhalation  when  protracted,  and  a  warm  or  cold 
bath  according  to  the  degree  of  fever.  For  the  paralysis  much  can  be 
accompHshed  by  persistent,  systematic  massage,  little,  if  anything,  by 
electricity,  and  the  child  should  be  encouraged  and  taught  to  use  the 
paralyzed  members.  The  mental  condition  can  be  improved  also  by 
proper  instruction  in  an  institution  for  the  feeble-minded  or  by  a  trained 
tutor.  Little  is  to  be  expected,  however,  when  a  condition  of  idiocy 
exists;  imbecility  often  increases,  but  when  the  mental  development  is 
merely  retarded,  remarkable  results  are  often  obtained. 

ACUTE  ENCEPHALITIS. 

INFLAMMATION  OF  THE  BRAIN,  ACUTE  CEREBRITIS. 

Inflammation  of  the  brain  may  be  localized  (focal)  or  diffuse;  it 
may  develop  independently  or  in  connection  with  meningitis.  It  usually 
results  from  injury,  embolism,  or  thrombosis;  poisoning  by  ptomains, 
alcohol,  illuminating  gas;  malignant  endocarditis  or  acute  infectious 
diseases,  particularly  influenza.  It  is  seen  especially  in  the  insane.  The 
histological  appearances  are  the  same  as  those  of  acute  poliomyelitis. 
In  the  focal  form  the  affected  areas  are  often  intensely  hyperemic,  but 
they  sometimes  show  little  change  at  autopsy.  The  hyperemia  is  less 
marked  in  any  case  in  which  the  brain  is  not  examined  until  after  the 
chest  has  been  opened. 

The  symptoms  are  often  obscure,  resembling  an  acute  infection,  with 
headache,  vomiting,  constipation,  restlessness,  sometimes  passing  into 
delirium  or  coma.  Paralyses  of  different  types,  muscular  spasm  and  par- 
esthesia, are  often  developed.  The  disease  usually  terminates  fatally 
within  a  few  weeks,  but  sometimes  after  several  months.  The  treat- 
ment is  that  of  meningitis. 

SUPPURATIVE  ENCEPHALITIS. 

ABSCESS  OF  THE  BRAIN. 

Etiology. — The  disease  may  occur  at  any  age,  but  it  is  somewhat 
more  frequent  in  middle-aged  men.  It  is  rarely,  if  ever,  primary,  al- 
though the  cause  cannot  always  be  determined.  In  most  cases  it  is  a 
result  of  the  extension  of  suppurative  inflammation  from  contiguous 
parts,  trauma,  or  embolism;  occasionally  of  tumor,  (a;)  The  most  fre- 
quent source  of  suppurative  inflammation  in  the  vicinity  is  a  chronic  otitis, 
especially  after  involvement  of  the  mastoid  cells.  The  abscess  has  been 
traced  also  to  a  suppurative  rhinitis,  abscess  of  the  frontal  sinus,  and 
to  suppuration  or  the  injury  caused  by  a  foreign  body  in  the  orbit. 


668  PRACTICE  OF  MEDICINE 

Qb')  Blows,  and  more  particularly  penetrating  wounds  of  the  skull,  are 
a  frequent  cause,  especially  when  the  brain  is  lacerated,  or  when  sup- 
puration develops  in  the  wound,  (r)  The  third  source  of  the  disease  is 
the  transmission  of  septic  emboli  from  a  suppurative  focus,  notably  in 
pyemia,  malignant  endocarditis,  occasionally  from  bronchiectasis,  septic 
pneumonia,  suppuration  of  bone,  gangrene  of  the  lung,  or  abscess  of  the 
liver.  It  may  follow  an  acute  infection,  particularly  influenza,  and  it  has 
resulted  from  ligation  of  the  external  carotid  too  near  to  its  origin. 

Morbid  Anatomy. — There  may  be  but  one  abscess  or  many.  The 
solitary  abscess  usually  varies  from  an  inch  to  two  inches  (2.5 — 5.0 
cm.)  in  diameter;  rarely  a  lobe  or  hemisphere  is  almost  completely 
excavated  by  it.  Multiple  abscesses  are  usually  small.  All  the  pus- 
forming  bacteria  may  be  found  in  the  pus,  and  other  micro-organisms 
are  occasionally  met  with.  In  the  rapidly  fatal  cases  the  suppuration 
is  diffused,  but  in  cases  of  long  standing  a  distinct  wall  is  formed.  The 
pus  has  an  acid  reaction,  may  be  tinged  with  blood  and  the  debris  of 
the  brain  substance,  but  it  has  usually  a  greenish  color  and  a  strong 
odor  of  hydrogen  sulphid.  Any  part  of  the  brain  may  be  the  seat  of 
suppuration,  especially  the  temporal  lobe  and  the  cerebellum.  The  over- 
lying membranes  are  involved  in  the  inflammation  when  the  abscess  is 
near  the  surface.  The  surrounding  brain  substance  is  inflamed  or  de- 
generated and  always  compressed. 

Symptoms. — The  symptoms  may  develop  suddenly  with  chills  and 
fever,  or  a  convulsion  in  a  child,  headache,  nausea,  vomiting,  delirium 
or  coma,  especially  in  traumatic  cases  or  those  due  to  otitis.  In  other 
cases  the  manifestations  are  exceedingly  vague  or  they  may  resemble 
meningitis  or  meningoencephalitis  for  days  and  weeks,  until  localizing 
symptoms  develop.  These  frequentl}'  do  not  appear,  however,  until  a 
large  area  of  brain  substance  has  been  destroyed,  especially  in  the  an- 
terior lobe  of  the  cerebrum.  The  pupils  may  be  dilated  or  unequal  and 
optic  neuritis  may  exist.  Hemianopia  has  been  observed.  The  tempera- 
ture is  not  high  when  the  membranes  are  not  involved,  and  it  may  be 
subnormal,  even  as  low  as  97°  or  96°  F.  (36.0° — 35.6°  C.)  until  near 
the  termination  of  the  disease.  The  pulse  may  be  accelerated,  but  is 
often  slow  as  60  or  less.    Leucocytosis  is  present. 

The  localizing  symptoms  depend  upon  the  situation  of  the  abscess, 
and  may  be  exceedingly  confusing  when  several  foci  of  suppuration  are 
present.  They  consist  of  different  paralyses,  aphasia,  irregular  respira- 
tion, rigidity,  spasm,  convulsions,  and  other  manifestations  of  cerebral 
disease.  The  cranium  may  be  tender,  especially  upon  percussion,  and 
slight  resonance  over  the  compressed  portion  of  the  brain  has  been 
described.  Symptoms  of  sepsis  may  develop  toward  the  termination  of 
the  disease. 

Diagnosis. — The  diagnosis  is  usually  difiEicult,  except  in  traumatic 
cases.  The  persistent,  severe  headache,  stupor,  gastric  irritability,  low 
temperature,  leucocytosis,  inequality  of  the  pupils,  retinitis,  delirium, 
and  the  localizing  symptoms  arouse  suspicion  of  the  disease,  but  do  not 
always  afford  data  for  a  differentiation  from  brain  tumor  unless  a  prob- 
able cause  of  abscess  has  been  discovered.  When  these  symptoms  fol- 
low injury  or  suppuration,  and  when  chills  or  convulsions  with  fever 
supervene,  the  diagnosis  is  practically  established. 


CHRONIC  MENINGOENCEPHALITIS  669 

Prognosis. — The  disease  is  fatal  except  in  those  cases  in  which  the  ab- 
scess can  be  evacuated.  Death  may  occur  within  a  week  or  two,  or  not 
for  several  months. 

Treatment. — The  medical  treatment  is  purely  palliative.  Remarkable 
success   has  followed  evacuation  and  drainage  of  the  abscess   in  some 


CHRONIC  MENINGOENCEPHALITIS. 

DEMENTIA    PARALYTICA,  GENERAL  jPARESIS,   PROGRESSIVE  PARALYSIS  OF 

THE  INSANE. 

Definition. — A  slowly  progressive  inflammation  and  degeneration  of 
the  brain  and  meninges  characterized  by  psychical  and  motor  disturb- 
ances and  leading  to  dementia  and  paralysis. 

Etiology. — The  disease  is  more  frequent  in  men  than  women,  and  be- 
tween the  ages  of  20  and  50.  It  is  a  product  of  the  mental  strain  and 
worry,  the  ambition  and  constant  struggle,  the  "  strenuous  life"  of  our 
age,  but  in  more  than  three-fourths  of  all  cases  it  attacks  individuals 
who  have  been  the  victims  of  syphilis.  Alcoholism  is  a  most  potent 
cause  in  the  syphilitic  subject.  Sexual  excess,  loss  of  rest,  deferred  hopes, 
disappointment,  and  business  reverses  are  important  factors  in  many 
cases.    The  frequency  of  the  disease  has  doubled  in  the  last  half-century. 

Morbid  Anatomy. — The  disease  usually  begins  with  inflammatory 
changes  in  the  adventitia  of  the  blood-vessels  of  the  brain,  and  degen- 
erative changes  in  the  brain  substance  follow.  The  membranes  are 
found  in  a  state  of  chronic  diffuse  meningitis,  thickened,  opaque,  and 
hyperemic.  The  pia  is  also  opaque,  thick,  and  adherent  to  the  cortex, 
but  may  later  become  detached.  As  the  disease  progresses,  the  hemi- 
spheres undergo  atrophy,  particularly  in  the  frontal  and  parietal  con- 
volutions, so  that  they  appear  small  and  weigh  less  than  normal.  The 
gray  matter  is  especially  reduced.  Hemorrhagic  points  or  areas  of  pig- 
mentation are  generally  found.  The  microscope  reveals  fatty  and  other 
degeneration  of  the  nerve  elements  and  hyperplasia  of  the  connective 
tissue. 

Symptoms.— The  clinical  history  is  divided  into  three  stages,  which 
are  usually  fairly  distinct — the  prodromal,  the  maniacal,  and  the  stage 
of  dementia. 

I.  Prodromal  Stage.— The  important  feature  of  this  stage  is  a  change, 
a  deviation,  in  some  particular  from  the  normal  traits,  habits,  or  dis- 
position of  the  individual.  There  may  be  merely  an  exaggeration  of 
the  natural  characteristics,  or  a  complete  reversal  of  them.  The  business 
man  becomes  unnaturally  ambitious  and  optimistic  in  his  affairs,  or 
careless  and  indiff'erent,  forgetful  of  engagements  and  promises,  or  reck- 
less in  investments.  The  man  of  gentle  manners  becomes  more  quiet 
and  reserved,  or  rude,  profane,  vulgar,  and  utterly  lawless.  His  con- 
duct at  home  is  often  the  reverse  of  that  among  other  associates.  He 
becomes  irritable  and  morose,  abuses  his  family,  and  possibly  deprives 
them  of  all  comforts,  to  spend  his  wealth  lavishly  upon  the  courtesan 
and  other  new  associates.  In  many  cases  there  is  extreme  exaltation. 
A  man  of  moderate  means  boasts  of  fabulous  wealth.  He  subscribes 
freely  to  charity,   buys  blocks  of  the  most  worthless  stocks,   and   fre- 


670  PRACTICE  OF  MEDICINE 

quently  squanders  a  fortune  before  his  condition  has  been  recognized. 
A  characteristic  feature  of  the  disease  is  the  fact  that  the  patient  cannot 
be  forced  into  an  explanation  of  his  suddenly  acquired  wealth.  Although 
previously  showing  little  affection,  he  may  suddenly  become  extremely 
fond  of  his  wife  and  children  and  boastful  of  them  in  the  presence  of 
others. 

In  many  cases  even  during  this  stage  a  tremor  of  the  tongue  and 
lips  is  apparent,  and  the  patient  may  speak  with  unusual  deliberation 
and  some  difficulty.  He  generally  becomes  fatigued  after  slight  exertion. 
The  Argyll  Robertson  pupil  or  an  unequal  dilatation  may  be  present. 

2.  The  acute  or  maniacal  stage  is  marked  by  an  exaggeration  of 
all  the  features  of  the  prodromal.  His  egoism  becomes  expanded  until 
his  wealth  is  no  longer  within  the  bounds  of  figures;  his  strength  is 
that  of  a  Hercules,  and  he  is  in  a  constant  state  of  excitement,  restless, 
sleepless,  often  furious  and  violent.  In  some  cases,  however,  the  con- 
dition is  directly  the  reverse,  and  the  patient  becomes  melancholic  and 
hypochondriacal,  or  he  may  have  alternating  attacks  of  depression  and 
buoyancy,  mania,  or  delirium.  The  face  assumes  a  fixed  expression, 
the  tongue  and  lips  become  more  tremulous,  so  that  the  tongue  may 
be  protruded  with  difficulty,  and  the  speech  becomes  drawling  and  in- 
distinct. The  handwriting  is  also  tremulous  and  irregular,  and  words 
or  parts  of  words  are  omitted.  The  eye  symptoms  are  more  constantly 
observed  in  this  stage,  and  the  tremor  affects  also  the  fingers  and  toes. 
All  these  symptoms  are  subject  to  periodical  exacerbation  and  remission. 
The  knee-jerk  is  usually  increased,  but  it  may  be  normal  or  absent. 
Transient  incontinence  of  urine  sometimes  occurs. 

The  evidences  of  paresis  are  often  first  seen  in  the  face  as  a  partial 
obliteration  of  the  nasolabial  fold,  or  in  the  tongue  as  a  slight  devia- 
tion to  one  side.  Spinal  symptoms  like  those  of  locomotor  ataxia  some- 
times precede  the  mental,  and  the  patient  has  difficulty  in  walking,  es- 
pecially in  going  up  and  down  stairs. 

3.  In  the  stage  of  dementia  and  paralysis  the  delusions  of  grandeur 
and  wealth  give  place  to  emotional  disturbances,  sometimes  character- 
ized by  great  religious  fervor,  sometimes  by  deep  melancholia  and  depres- 
sion. Epileptic  seizures  or  brief  attacks  of  petit  mal  sometimes  occur 
as  the  disease  progresses.  The  face  becomes  flushed,  the  breathing  ster- 
torous, and  there  is  brief  unconsciousness,  or  the  patient  may  fall  and 
the  paroxysm  may  prove  fatal. 

Paralysis  soon  becomes  a  prominent  feature,  and  the  patient  becomes 
bedridden,  the  helplessness  increases,  emaciation  becomes  extreme,  and 
extensive  bedsores  develop.  Death  finally  ensues  from  exhaustion  or 
an  intercurrent  disease,  particularly  bronchopneumonia. 

Diagnosis. — The  diagnosis  is  based  upon  the  gradual  change  of  dispo- 
sition and  habits,  the  delusions  of  grandeur  or  depression,  the  tremor, 
ocular  symptoms,  and  the  affection  of  speech.  In  the  later  stages  there 
is  rarely  difficulty  in  its  recognition.  Cerebral  syphilis  is  generally  to 
be  distinguished  by  the  early  development  of  paralysis,  not  usually 
affecting  the  speech  or  the  tongue.  Epileptic  seizures  are  more  common 
and  occur  earlier,  and  delusions  are  not  usually  present. 

Prognosis. — The  disease  terminates  fatally  in  from  one  to  five  years, 
as  a  rule,  seldom  before  two  years,  but  occasionally  exceeding  ten. 


SCLEROSIS  OF  THE  BRAIN  671 

rreaf/we/7f.— Potassium  iodid  should  be  administered  early  in  full 
doses,  whether  or  not  a  history  of  syphilis  can  be  elicited.  The  nerv- 
ousness and  sleeplessness  call  for  the  administration  of  large  doses  of 
the  bromids.  The  bowels  should  be  kept  active.  The  patient  should  be 
early  sent  to  an  asylum,  where  the  regular  life  and  constant  attention 
often  add  much  to  his  comfort  and  prevent  unfortunate  accidents.  In  the 
last  stages  great  care  must  be  exercised  to  prevent  bedsores.  When  so 
desired,  this  stage  may  be  passed  in  the  care  of  a  good  nurse  at 
home. 

SCLEROSIS  OF  THE  BRAIN. 

Efio/ogy.— Sclerosis  is  generally  a  disease  of  early  adult  life,  but  it 
has  been  repeatedly  observed  in  children,  and  a  few  congenital  cases  have 
been  described.  It  may  be  caused  by  any  influence  which  is  capable  of 
producing  irritation  of  the  connective  tissue  of  the  brain,  the  most 
prominent  of  which  are  :  (a)  The  toxins  of  the  infectious  diseases,  par- 
ticularly syphilis;  (<^)  metallic  poisons,  especially  lead;  (^)  acute  in- 
flammation (encephalitis) ;  and  (a;')  degeneration  of  the  nerve-fibers. 
(^)  A  capsular  area  of  sclerosis  forms  also  around  foreign  bodies,  ab- 
scesses and  tumors,  as  in  other  situations. 

Morbid  Anatomy. — The  process  may  involve  the  neuroglia,  fibrous 
tissue  of  the  meninges,  and  walls  of  the  blood-vessels.  The  lesions  are 
grouped  under  four  heads  :  Qa)  The  diffuse,  affecting  all  parts  of  the 
brain  and  peculiar  to  idiocy  and  imbecility;  (^)  the  miliary,  in  which 
exceedingly  small  sclerotic  areas  are  scattered  over  the  surface  or 
throughout  the  substance  of  the  brain ;  (<-)  the  tuberous,  in  which  hy- 
pertrophic sclerosis  produces  large  white  nodules  on  the  surface  of  the 
convolutions;  and  Qcf)  insular  sclerosis.  It  is  only  the  last  of  these 
that  produces  definite  manifestations. 

INSULAR  SCLEROSIS. 

Multiple    Cerebrospinal    Sclerosis,    Disseminated    Sclerosis,     Sclerose    en 

Plaques. 

Definition. — A  chronic  disease  of  the  brain  and  cord  due  to  the  de- 
velopment of  disseminated  sclerotic  areas  at  the  expense  of  the  nerve- 
tissues. 

Etiology. — The  disease  attacks  either  sex  at  the  ages  and  as  a  re- 
sult of  the  influences  already  stated.  Syphilis  and  the  acute  infectious 
diseases,  particularly  scarlatina,  are  the  most  important  factors.  Some 
cases  follow  exposure  to  cold  and  wet. 

/I/forbid  Anatomy. — The  sclerotic  areas  are  firm  and  of  a  reddish  gray 
^olor,  regular  contour,  discrete  or  confluent,  and  consist  of  reticulated 
connective  tissue.  They  may  be  found  in  either  the  gray  or  white  matter 
and  are  generally  found  in  the  walls  of  the  ventricles,  in  the  centrum 
ovale,  corpus  callosum,  septum  lucidum,  optic  thalamus,  corpus  stria- 
tum, sometimes  in  the  cerebellum,  pons  and  medulla,  and  throughout 
the  spinal  cord.  In  some  cases  the  brain  or  cord  is  affected  alone;  in 
others  both  are  involved.  Arteriosclerosis  is  also  associated  with  these 
lesions.  The  myalin  sheaths  are  early  destroyed,  but  the  axis  cylinders 
(axons)  remain  normal. 


672  PRACTICE  OF  MEDICINE 

Symptoms. — The  disease  usually  develops  slowly,  often  with  (a)  slight 
weakness  and  incoordination,  and  possibly  some  pain  in  the  lower  ex- 
tremities. The  reflexes  are  increased  and  the  condition  may  resemble 
spastic  paraplegia.  With  this,  or  before  it,  ((5)  a  tremor  develops  which 
is  known  as  the  intention  tremor  or  volition  tremor,  from  the  fact  that 
it  occurs  only  when  voluntary  movements  are  made,  as  when  the  patient 
attempts  to  write  or  to  Hft  a  glass  of  water  to  his  lips.  It  usually  dis- 
appears when  he  is  at  rest.  It  is  ordinarily  a  fine  tremor,  but  it  may 
become  extremely  coarse  when  strong  efforts  are  made.  Qc)  Slight  pare- 
sis generally  accompanies  the  tremor;  the  grasp  of  the  hand  is  feeble. 
(,^)  Nystagmus  usually  develops  during  voluntary  movement.  (^)  Scan- 
ning or  staccato  speech  is  one  of  the  most  important  symptoms.  The  pa- 
tient hesitates,  tremulous  movements  of  the  tongue  and  hps  occur,  and 
the  words  are  uttered  slowly  and  separately,  or  each  syllable  is  accented. 
(/)  Other  more  or  less  constant  symptoms  are  vertigo,  atrophy  of  the 
optic  nerve,  and  a  great  variety  of  symptoms  of  a  localizing  character 
depending  upon  the  situation  of  the  lesion  and  embracing  the  mani- 
festations of  nearly  all  the  other  diseases  of  the  central  nervous  system. 
The  course  of  the  disease  is  exceedingly  chronic ;  it  may  terminate  sud- 
denly in  an  apoplectic  seizure  similar  to  those  of  paresis,  or  the  latter 
disease  may  develop. 

Diagnosis. — The  disease  is  distinguished  from  paralysis  agitans  by  the 
absence  of  tremor  during  rest  and  the  occurrence  of  nystagmus.  From 
general  paresis  it  is  distinguished  by  the  absence  of  early  delusions  and 
the  ocular  symptoms.  Hysteria  sometimes  imitates  the  other  symp- 
toms, but  seldom  the  intention  tremor  and  never  the  nystagmus. 

Prognosis. — The  disease  is  incurable,  but  it  may  last  for  many  years 
with  intervals,  and  the  patient  finally  succumbs  to  exhaustion  or  an 
intercurrent  disease. 

TUMORS  AND  CYSTS  OF  THE  BRAIN. 

Etiology. — Tumors  may  occur  at  any  age,  but  rarely  before  the  tenth 
year,  and  most  frequently  between  the  twentieth  and  fortieth.  Males 
are  more  commonly  affected.  Tubercular  granulomata  are  more  fre- 
quent in  childhood,  syphiHtic  in  adult  life.  Sarcoma  and  carcinoma 
are  generally  met  with  at  a  later  period  than  these.  Heredity  can  sel- 
dom be  traced  except  in  tuberculosis  and  cancer.  Some  tumors  follow 
prolonged  nerve-strain,  and  others  can  be  traced  to  injur}^ 

l^orbid  Anatomy. — The  growth  may  be  single  or  multiple,  benign 
or  malignant,  and  histologically  may  belong  to  the  epithelial,  connec- 
tive-tissue, or  nerve-tissue  type.  Tubercular,  syphilitic,  and  aneurismal 
growths  are  more  frequent  forms  of  multiple  neoplasms.  Enchondro- 
mata  and  osteomata  develop  from  the  bones  of  the  skull  or  from  the 
falx  cerebri.  Ghomata,  fibromata,  myxomata,  lipomata,  cholesteomata, 
adenomata,  angiomata,  and  neuromata  are  occasionally  found.  The 
ray  fungus  is  sometimes  found  as  an  invasion  from  the  face.  Of  cysts, 
the  cysticercus,  echinococcus,  and  cavities  formed  by  congenital  atrophy, 
hemorrhages,  or  the  softening  due  to  disease  are  the  usual  types. 

Symptoms.— The  clinical  manifestations  are  of  two  kinds,  general 
and  localizing  or  focal. 


TUMORS  AND  CYSTS  OF  THE  BRAIN  673 

1.  General  6)'»?//^»w.^Persistent  headache  is  the  most  frequent  of 
these.  It  is  not  usually  violent,  but  it  is  often  accompanied  with  tender- 
ness. Vertigo  and  projectile  vomiting,  often  without  distinct  nausea, 
are  usually  persistent  symptoms.  Local  or  general  convulsions  of  an 
epileptic  type  are  present  in  many  cases.  Optic  neuritis  (choked  disk) 
is  found  in  a  majority  of  cases,  estimated  by  some  authors  as  high  as 
60  to  80  per  cent,  at  some  time  in  the  course  of  the  disease,  yet  mania, 
delirium,  and  the  eye  symptoms  of  general  paresis  are  sometimes  ob- 
served. As  a  rule,  however,  they  are  more  in  the  nature  of  hebetude. 
Somnolency  or  coma  may  develop.  Variations  in  the  character  of  the 
pulse  and  respiration  often  occur,  and  the  pupils  may  be  affected,  but 
in  no  characteristic  manner.  Fever  is  not  present.  Trophic  changes,  as 
bedsores  and  paralysis  of  the  sphincters,  often  develop  toward  the  close. 

2.  Focal  Symptoms. — These  depend  wholly  upon  the  situation  of  the 
growth.  They  may  be  indirectly  produced  by  pressure,  however,  in  the 
larger  tumors.  Small  neoplasms  confined  to  a  single  area  produce  the 
most  typical  symptoms,  among  which  the  following  may  be  studied : 

a.  Motor  Area. — Localized  muscle  spasms,  followed  by  monoplegia, 
or  more  extensive  convulsive  movements  with  other  types  of  paralysis. 
Spasm  with  a  tingling  sensation  confined  to  a  single  muscle  group 
has  been  denominated  a  signal  symptom  by  Seguin. 

b.  Psychical  Centers. — The  frontal  lobes  were  formerly  regarded  as  the 
seat  of  the  metaphysical  mind,  but  at  the  present  time  the  integrity  of 
the  mind  is  believed  to  depend  upon  the  total  integrity  of  the  cortex; 
hence  any  destructive  lesion  of  this  area  may  be  attended  with  mental 
disturbance. 

c.  Prefrontal  Region. — Mental  disturbances  and  sometimes  disorders  of 
the  sense  of  smell. 

d.  Third  Left  Frontal  Convolution. — Motor  aphasia.  The  patient  un- 
derstands the  meaning  of  words,  but  cannot  utter  them  properly. 

e.  Island  of  Reil. — Aphasia  of  conduction.  The  patient  utters  words 
entirely  different,  sometimes  having  a  contrary  meaning  to  that  he  de- 
sires to  express. 

f  Parietal  Region. — Word-blindness  or  mental  blindness.  In  the  former 
the  patient  can  repeat  or  write  a  word,  but  cannot  comprehend  its 
meaning;  in  the  latter  he  sees  objects,  but  cannot  recognize  them. 

g.  Temporal  Region. — Word-deafness  or  psychical  deafness.  \\'ords 
are  heard,  but  not  comprehended.   Symptoms  may,  however,  be  absent. 

h.  Occipital  Lobe. — Hemianopia,  or  total  blindness  when  both  sides 
are  affected.  When  on  the  left  side,  word-blindness  or  psychic  blindness 
may  be  produced. 

i.  Basal  Ganglia. — Hemiplegia  of  the  opposite  side,  sometimes  hemi- 
anopia. 

j.  Corpora  Qnadrigemiiia  (Usually  Involving  also  the  Crura). — Nys- 
tagmus with  loss  of  pupil  reflexes,  hemiplegia  of  the  opposite  side,  and 
oculomotor  paralysis  on  the  same  side. 

k.  Cerebellum. — Symptoms  may  not  be  produced,  or  there  may  be 
vertigo,  projectile  vomiting,  optic  neuritis,  pain  in  the  cervical  region, 
and  incoordination  with  a  peculiar  reeling  gait,  always  turning  toward 
the  same  side. 

/.   Pons  and  Medulla. — Involvement   of  the  cranial  nerves,   dyspnea, 

43 


674  PRACTICE  OF  MEDICINE 

disturbance  of  the  heart's  action,  sometimes  hemiplegia,  sensory  and 
other  disturbances. 

Diagnosis. — The  gradually  increasing  intensity  of  the  general  symp- 
toms described  is  ordinarily  sufficient  for  diagnosis.  It  should  be  remem- 
bered, however,  that  chronic  nephritis,  lead-poisoning,  tobacco,  mye- 
litis, multiple  sclerosis,  and  other  affections  are  often  attended  with 
symptoms  suggestive  of  brain  tumor. 

Prognosis. — All  forms  of  brain  tumor  are  fatal  except  the  tubercular 
and  syphilitic.  Death  may  occur  suddenly  or  it  may  be  delayed  for  many 
months.    Some  cases  are  amenable  to  surgical  treatment. 

Treatment. — The  therapeutic  test  of  large  doses  of  potassium  iodid 
should  be  made  in  every  case.  Temporary  improvement  is  often  obtained 
even  in  nonsyphilitic  cases.  When  this  fails,  surgical  measures  should 
be  considered.  Operation  is  indicated  only  in  definitely  localized  tumors 
of  the  dura  or  cortex.  An  exploratory  operation  is  generally  justi- 
fiable. In  other  cases  the  treatment  is  palliative,  limited  to  measures 
for  the  comfort  of  the  patient.  Spontaneous  recovery  sometimes  occurs 
in  a  tuberculous  case,  and  it  may  be  assisted  by  the  administration 
of  tonics  and  the  general  measures  for  the  treatment  of  tuberculosis. 
An  ice-cap  should  be  worn  to  relieve  the  headache.  Large  doses  of  the 
bromids  and  the  coal-tar  preparations  may  be  tried,  but  they  generally 
fail  to  relieve  it.     Morphin  should  be  administered  in  a  hopeless  case. 

APHASIA. 

Definition. — Aphasia,  or  loss  of  the  power  of  speech  as  a  result  of  cor- 
tical lesions,  is  a  not  infrequent  accompaniment  of  diseases  and  injury 
of  the  brain.    It  may  be  motor  or  sensory  in  character. 

Etiology. — The  causes  embrace  all  the  causes  of  cortical  affections, 
particularly  trauma,  hemorrhage,  arteriosclerosis,  embolism,  thrombosis, 
and  tumors,  especially  when  the  third  frontal  convolution  is  involved. 
Different  varieties  of  aphasia  are  recognized  as  a  result  of  disconnection 
of  the  centers  of  hearing,  sight,  and  motion,  involved  in  the  comprehen- 
sion of  language  and  production  of  articulate  sound. 

Symptoms. — i.  Motor  Aphasia  (Ataxic  Aphasia.) — The  lesion  in  this 
form  of  aphasia  is  generally  situated  in  the  posterior  part  of  the  third 
left  frontal  convolution.  The  individual  comprehends  words  and  can 
remember  them ;  in  rare  cases  he  is  able  to  write  them  and  to  understand 
what  is  written,  though  agraphia  is  more  frequently  associated  with  the 
condition,  yet  he  is  unable  to  utter  a  word.  In  many  cases  the  ability 
is  retained  to  utter  a  few  words,  often  only  a  single  word,  and  every 
effort  to  speak  calls  forth  the  stock  word  or  phrase.  In  another  group 
of  cases  there  is  what  is  termed  aphasia  of  conduction.  In  this  also 
the  patient  understands  the  meaning  of  words  and  can  write  from  dic- 
tation, but  cannot  express  them. 

Word-dumbness  is  a  rare  form  in  which  the  individual  can  read  to 
himself,  but  can  neither  speak  spontaneously  nor  repeat  words  that  are 
spoken  to  him. 

Transcortical  motor  aphasia  is  another  rare  form  in  which  the  patient 
understands  what  is  said,  can  read  aloud  and  write  from  copy  or  dic- 
tation, but  cannot  speak  or  write  from  his  own  volition. 


HYDROCEPHALUS  675 

2.  Sensory  Aphasia. — In  this  form  of  the  affection,  often  termed  mind- 
bhndness,  visual  amnesia  or  apraxia,  there  is  an  interruption  of  the 
auditory  and  visual  communication  with  the  motor  centers  of  speech. 
In  many  cases,  indeed,  the  perception  conveyed  by  any  of  the  senses 
fails  to  excite  the  centers  of  speech,  and  may  fail  entirely  of  recognition. 
The  patient  sees,  hears,  smells,  tastes,  and  touches  objects,  but  cannot 
recognize  or  name  them.  In  rare  instances  recognition  remains  through 
one  of  the  senses,  particularly  that  of  touch.  The  patient  may  be  able 
to  read  aloud  without  understanding  what  he  reads.  The  situation  of 
the  lesion  is  believed  to  be  in  the  angular  and  supramarginal  convo- 
lution. Several  other  terms  are  employed  to  designate  peculiar  conditions, 
as  word-blindness  when  the  patient  does  not  comprehend  written  or 
printed  words.  He  may  be  able  to  write  correctly,  but  cannot  read 
what  he  has  written. 

Word-deafness  is  a  condition  in  which  the  patient  cannot  understand 
spoken  language. 

In  mind-deafness  the  patient  does  not  comprehend  sounds.  The  ring- 
ing of  a  bell  or  the  barking  of  a  dog  fails  to  arouse  a  concept  of  the 
object  producing  the  sound. 

In  apraxia  proper  there  is  a  dissociation,  not  only  of  the  centers 
involved  in  the  use  of  language,  but  of  all  the  sensory  centers,  and  the 
individual  can  neither  recognize  objects  nor  make  proper  use  of  them. 

Agraphia  is  the  term  applied  to  the  condition  in  which  the  individual 
is  unable  to  express  his  thoughts  in  writing.  Alexia  signifies  an  inability 
to  understand  words  which  the  patient  may  be  able  to  read  aloud. 
In  most  cases  two  or  more  of  these  conditions  are  associated. 

Prognosis. — The  completeness  of  recovery  depends  in  part  upon  the 
character  of  the  lesion  and  in  part  upon  the  age  of  the  patient.  Young 
subjects  usually  recover,  probably  through  the  education  of  centers  on 
the  opposite  side  of  the  brain.  In  adults  with  hemiplegia  the  prospect 
is  less  favorable.  Sensory  aphasia  is  generally  less  permanent  than 
motor  aphasia. 

Treatment.— The  treatment  of  the  lesion  is  that  of  hemiplegia.  The 
aphasia  is  to  be  overcome,  if  at  all,  through  the  re-education  of  the  pa- 
tient as  in  childhood. 

HYDROCEPHALUS. 

I.  External  or  Subdural  Hydrocephalus.— A  chronic  condition  in 
which  the  arachnoid  space  is  distended  with  fluid.  It  may  be  a  congeni- 
tal condition,  a  result  of  arrested  brain  development,  or  excessive  growth 
of  the  skull.  In  other  cases,  without  atrophy,  the  subdural  fluid  be- 
comes excessive  and  the  cranium  enlarges  without  recognizable  cause. 
In  some  instances  the  fluid  becomes  sacculated  through  the  formation 
of  adhesions,  doubtless  inflammatory,  between  the  dura  and  pia.  This 
may  lead  to  unilateral  dilatation  of  the  skull.  Hydrocephalus  may  re- 
sult from  rickets  in  childhood  and  may  follow  hemorrhage,  softening, 
or  sclerosis  in  adults.  It  is  most  frequent,  however,  in  advanced  life  as 
a  result  of  atrophy  (hydrocephalus  ex  vacuo).  The  cranium  becomes  ex- 
ceedingly thin  in  children,  and  the  fontanels  widely  open.  The  dura  may 
remain  unchanged,  but  the  cerebral  cortex  is  thinned  through  pressure. 


676  ■  PRACTICE  OF  MEDICINE 

The  symptoms  are  variable;  in  some  cases  there  are  no  distinctive 
manifestations.  In  children,  however,  idiocy  is  generally  produced;  in 
the  aged,  a  condition  of  dementia. 

2,  Internal  or  Ventricular  Hydrocephalus.— A  chronic  distention  of 
the  ventricles  of  the  brain  with  serous  fluid. 

Etiology. — The  condition  may  be  congenital  or  acquired.  In  the  for- 
mer class  of  cases  it  sometimes  appears  to  be  hereditary  and  may  af- 
fect several  members  of  a  family.  The  acquired  form  usually  results 
from  meningitis,  tumor,  abscess,  obstruction  of  the  vense  Galeni,  or  from 
an  unknown  cause.  Tumors  sometimes  operate  by  preventing  the  es- 
cape of  fluid  from  the  ventricles. 

Morbid  Anatomy. — In  congenital  cases  the  cranium  becomes  greatly 
distended  and  thin,  the  fontanels  enlarged,  and  the  sutures  separated. 
Wormian  bones  may  develop  in  the  spaces.  Changes  in  the  brain  re- 
sult from  the  compression.  The  fluid  may  be  confined  to  the  fourth 
ventricle  alone,  to  the  third  and  lateral  ventricles,  or  to  the  lateral  alone. 
The  quantity  of  fluid  varies  from  a  few  ounces  to  several  quarts.  It 
is  albuminous  and  has  a  specific  gravity  of  i.oio  or  1.012.  In  the  ac- 
quired form,  occurring  in  adult  life,  the  quantity  of  fluid  is  necessarily 
less,  and  the  compression  of  the  brain  substance  may  be  more  extensive 
owing  to  the  rigidity  of  the  skull. 

Symptoms. — In  the  congenital  form  the  enlargement  of  the  skull  gives 
the  child  a  typical  appearance.  It  sometimes  reaches  a  circumference  of 
twenty -four  to  thirty  inches  (60  to  75  cm.).  The  fontanels  are  widely 
open,  the  sutures  separated,  and  the  tables  of  the  skull  may  be  so  thin 
as  to  be  indented  by  slight  pressure.  The  orbital  plates  are  depressed, 
and  exophthalmos  is  produced.  The  subcutaneous  veins  become  promi- 
nent. The  face  appears  diminutive  in  comparison  to  the  skull,  and  the 
expression  is  aged. 

Various  nervous  manifestations  may  occur,  as  choreic  movements, 
nystagmus,  optic  neuritis,  conjugate  deviation  of  the  eyes,  sometimes  con- 
vulsions. The  child  is  unable  to  support  the  weight  of  the  head,  and 
rolls  it  from  side  to  side.  The  body  becomes  emaciated.  Arrest  of  in- 
tellectual development  may  occur,  but  the  mind  may  remain  active. 
Some  cases  are  bedridden,  others  can  walk. 

The  symptoms  in  adults  are  those  of  brain  tumor  without  localizing 
manifestations.  Headache,  stupHDr  or  coma,  optic  neuritis,  and  inco- 
ordination are  usually  present. 

Diagnosis. — In  cases  occurring  in  children  the  differentiation  must  be 
made  from  rickets.  This  is  not  usually  difficult,  since  the  enlargement 
®f  the  epiphyses  and  other  bone  changes  are  not  present  unless  the  two 
diseases  are  associated,  as  is  not  infrequently  the  case.  In  the  adult 
the  differentiation  from  brain  tumor  depends  chiefly  upon  the  absence  of 
focal  symptoms,  and  the  gradual  development  of  optic  neuritis. 

The  prognosis  is  exceedingly  unfavorable.  Death  may  occur  suddenly 
after  repeated  attacks  of  coma,  sometimes  lasting  for  several  weeks. 

Treatment. — Little  can  be  done  for  the  relief  of  the  condition.  \\Tien 
the  pressure  symptoms  become  urgent,  aspiration  of  the  ventricles  may 
be  antiseptically  performed.  Lumbar  puncture  is  a  safer  procedure 
and  may  prove  effective.  Strapping  and  compression  of  the  skull  with 
rubber  or  adhesive  bands  is  sometimes  practiced,   but  it  can  operate 


ACUTE  DELIRIUM  677 

only  by  increasing  the  pressure  upon  the  brain.  Potassium  iodid  and 
mercury  are  generally  administered,  but  without  marked  or  permanent 
benefit,  except,  perhaps,  in  some  cases  in  infants  with  syphilitic  taint. 
The  bromids  should  be  employed  to  relieve  the  restlessness. 


FUNCTIONAL  NERVOUS  DISEASES. 
ACUTE  DELIRIUM. 

ACUTE  MANIA,  TYPHOMANIA,  BRAIN    FEVER,  BELL'S  MANIA. 

Definiiion. — A  rare  and  rapidly  fatal  form  of  delirium,  characterized  by 
intermittent  outbreaks  of  violent  maniacal  excitement. 

Etiology. — This  affection  is  generally  encountered  in  distinctly  neurotic 
individuals,  often  in  those  who  have  been  subject  to  hysteria,  neuras- 
thenia, or  insanity.  The  exciting  causes  are  injury,  chronic  alcoholism, 
autointoxication,  acute  infection,  especially  typhoid  fever  or  pneumonia, 
and  sunstroke.     Many  cases  strongly  suggest  the  probability  of  infection. 

Morbid  Anatomy. — Hyperemia  of  the  cerebral  and  spinal  meninges  is 
found  after  death,  sometimes  the  gray  matter  is  congested.  Granular 
degeneration  of  the  cortical  ganglion  cells  and  engorgement  of  the  peri- 
ganglionic  spaces  with  leucocytes  have  been  observed  by  Spitzka.  Hypo- 
static congestion  of  the  lungs  or  deglutition  pneumonia  is  frequently 
found. 

Symptoms. — The  disease  may  be  divided  into  three  stages — the  pro- 
dromal, the  stage  of  excitement,  and  the  stage  of  collapse. 

1.  Prodromal  Stage. — This  is  usually  of  short  duration,  varying  from 
a  few  hours  to  several  days.  The  patient  presents  symptoms  like  those  of 
profound  autointoxication;  headache,  restlessness,  stupor,  furred  tongue, 
fetid  breath,  and  constipation,  and  he  becomes  rapidly  emaciated. 

2.  Stage  of  Excitement. — There  is  a  sudden  violent  outbreak,  in  which 
the  patient  has  hallucinations  of  sight  and  hearing,  screams,  strikes, 
kicks,  and  threatens  the  lives  of  those  about  him,  but  rarely  does  violence 
to  any  but  himself.  In  several  instances  he  has  gnawed  off  a  part  of  his 
finger.  He  may  escape  from  his  attendants,  naked  or  clothed.  There  is 
persistent  insomnia.  The  temperature  rises  to  103°  F.  or  higher.  The 
pulse  reaches  120  or  more  and  is  feeble.  The  patient  soon  sinks  into  a 
typhoid  state  bordering  on  collapse.  Hyperesthesia,  carphology,  and 
subsultus  are  generally  prominent,  and  the  reflexes  are  increased.  Sev- 
eral repetitions  of  the  attack  may  occur  before  the  final  stage  is  devel- 
oped, or  death  may  occur  after  the  first  seizure.  In  a  few  instances  deep 
melancholy  or  paresis,  with  cyanosis  and  sweating,  takes  the  place  of 
mania. 

3.  Stage  of -Collapse. — This  stage  is  all  that  the  name  implies.  The 
patient  is  completely  exhausted ;  his  temperature  remains  high,  the  pulse 
rapid  and  extremely  feeble,  the  respiration  irregular  and  weak,  the  pupils 
dilated,  and  the  face  expressionless.  In  a  few  cases  the  consciousness  re- 
turns at  intervals,  but  a  profound  coma  soon  ensues. 

Diagnosis. — The  sudden  development  of  violent  delirium,  with  fever  and 
emaciation,  renders  the  disease  easy  of  recognition.  In  memngitis  the 
invasion  is  slower,  the  delirium  less  violent  and  generally  of  a  muttering 


678  PRACTICE  OF  MEDICINE 

type.  There  are  photophobia  and  retraction  of  the  head.  Typhoid  fever 
can  be  distinguished  by  its  slow  onset,  the  rose  spots,  enlargement  of  the 
spleen,  and  Widal  reaction.  Acute  ma7iia  is  not  accompanied  with  fever  or 
so  rapid  emaciation.  Alcoholic  delirium  is  seldom  so  violent,  there  is  little 
or  no  fever,  and  it  occurs  only  in  those  addicted  to  excess.  It  must  be  re- 
membered, however,  that  acute  delirium  often  attacks  these  individuals. 

Prognosis. — The  disease  is  almost  invariably  fatal,  usually  within  a  few 
days,  or  the  patient  is  left  with  a  mental  defect  which  often  passes  into 
dementia  or  general  paresis. 

Treatment — The  bowels  should  be  thoroughly  evacuated  by  calomel, 
followed  with  a  saline  cathartic.  The  bromids  of  ammonium,  sodium 
and  potassium,  gr.  x  (0.65)  of  each,  should  be  given  every  three  hours. 
A  few  doses  of  hyoscin,  gr.  i-ioo  (0.0006),  should  be  given  during  the 
acute  stage.  Dram  doses  of  the  fluid  extract  of  ergot  every  two  hours 
have  been  highly  recommended.  An  equivalent  dose  of  ergotin  may  be 
administered  hypodermically.  Osier  advises  bloodletting,  even  in  the 
presence  of  bodily  prostration.  Cold  baths  or  the  cold  pack  has  a 
quieting  effect. 

PARALYSIS  AGITANS. 

SHAKING   PALSV,   PARKINSON'S  DISEASE. 

Definition. — A  chronic,  incurable  affection  of  advanced  life  in  which 
there  is  a  tremor  of  the  muscles,  with  gradual  loss  of  power  and  increas- 
ing rigidity,  a  characteristic  gait,  and  sensory  disturbances. 

Etiology. — The  disease  rarely  develops  before  the  fortieth  year,  but 
may  begin  as  early  as  the  twentieth  or  late  as  the  seventieth.  Men  are 
somewhat  more  frequently  affected.  A  tendency  to  nervous  disease  can 
sometimes  be  traced.  Among  the  exciting  causes  are  emotional  distur- 
bance, shock,  care,  worry,  fatigue,  exposure  to  cold  and  wet,  trauma,  as 
wounds  and  lacerations,  and  specific  fever,  as  malaria. 

Morbid  Anatomy. — No  lesions  in  any  way  distinctive  of  the  disease 
have  been  found  in  the  nervous  system. 

Symptoms. — The  characteristic  symptoms  are  tremor,  weakness,  rigid- 
ity, attitude,  and  gait.  Tremor  begins  slowly,  usually  as  a  fine,  constant 
or  intermittent  tremulousness  of  the  fingers  of  one  hand,  often  the  left. 
The  foot  of  the  same  side  next  becomes  affected.  In  some  cases  it  is 
confined  to  the  hands  alone  or  to  the  feet  alone.  As  a  rule,  the  hand 
becomes  afi^ected.  The  face-muscles  escape  the  tremor,  but  not  the  rigid- 
ity. The  tremor  ceases  during  sleep,  and  until  the  disease  becomes 
advanced  it  can  be  more  or  less  completely  arrested  for  a  short  time 
by  the  will  and  by  voluntar}^  motion.  All  the  exciting  causes,  fatigue, 
fright,  etc.,  are  capable  of  increasing  it.  The  movements  are  typical. 
The  thumb  and  finger  have  the  movement  of  rolling  a  pill ;  the  wrist  has 
all  the  motions  of  pronation,  supination,  flexion,  and  extension.  The 
head  nods.    The  rate  of  the  tremor  is  five  or  six  in  the  second. 

Weak?iess. — This  may  be  noticeable  at  the  beginning,  but  is  more 
marked  in  the  late  stages.  It  is  always  a  relative,  not  a  complete,  loss 
of  power. 

Rigidity. — This  affects  all  the  muscles  to  an  increasing  degree  and 
renders  all  movements  slow  and  deliberate. 


OTHER  TREMORS  679 

Attitude  and  Gait. — The  patient  stands  with  the  body  inclined  forward 
and  the  hands  drooping  in  front  of  him.  As  a  result  of  this  attitude 
there  is  a  tendency  to  move  forward  (propulsion).  Rarely  there  is  back- 
ward movement  (retropulsion),  and  more  rarely  lateral  movement  (lat- 
er opulsion).  The  gait  is  quick  and  shuffling.  The  face  becomes  expres- 
sionless, the  eyebrows  elevated,  the  voice  shrill  and  piping.  The  patient 
hesitates  in  the  beginning  of  speech,  then  speaks  rapidly. 

The  reflexes  are  normal  or  slightly  increased.  The  sensory  disturb- 
ances are  usually  limited  to  a  sense  of  heat  or  cold,  often  confined  to  one 
side.     Localized  sweating  often  occurs. 

Diagnosis. — The  symptoms  are  so  distinctive  as  to  leave  little  possi- 
bility of  error.  Disseminated  sclerosis  develops  in  younger  subjects,  as  a 
rule.  The  tremor  occurs  during  motion  and  ceases  during  rest.  The 
nystagmus,  scanning  speech,  and  paralysis  are  typical.  Postparalytic 
tremor   is   generally    unilateral    and   accompanied    with    paralysis    and 


/'^ 


Fig.  24. — Attitude  and  gait  in  paralysis  agitans.     (Dana.) 


greater  rigidity  of  the  aff"ected  muscles.     Senile  tremor  is  limited  to  the 
head,  hands,  and  fingers  in  extreme  old  age. 

Treaimeni. — The  patient  should  be  freed  from  care  and  worry.  The 
tremor  is  sometimes  diminished  by  the  administration  of  hyoscin  hydro- 
bromate.  Morphin  or  codein  is  more  eftective,  but  should  not  be  used 
until  it  becomes  imperative.  The  administration  of  arsenic  has  been 
followed  by  prolonged  improvement  in  some  cases.  Frequent  warm  baths, 
with  friction,  massage,  and  galvanization  of  the  limbs  and  spine,  are 
sometimes  of  benefit. 

OTHER  TREMORS. 

Simple  tremor  develops  in  those  debilitated  by  illness,  overwork,  inani- 
tion, or  without  discoverable  cause,and  may  be  of  short  or  long  duration. 

Toxic  tremor  follows  the  excessive  use  of  tobacco  or  alcohol  and 
poisoning  by  lead  or  other  metals,  and  affects  chiefly  the  hands  during 
voluntary  motion.    The  tongue  is  tremulous  in  alcoholic  cases. 


68o  PRACTICE  OF  MEDICINE 

Hereditary  Tremor.— Cases  of  this  character  have  been  reported  by 
C.  L.  Dana,  affecting  the  children  of  one  family  from  infancy. 

Senile  tremor  is  a  fine  tremulous  movement  of  the  fingers,  hands,  and 
head  in  extremely  old  persons  during  voluntary  movement. 

Hysterical  tremor  usually  accompanies  other  manifestations  of  hys- 
teria. It  affects  the  face  and  fingers  chiefly,  and  ceases  when  the  atten- 
tion is  diverted. 

ACUTE   CHOREA. 

CHOREA  MINOR.   SYDENHAM'S  CHOREA. 

Definition.^A-  functional  disorder  of  the  nervous  system  in  childhood 
and  youth  marked  by  a  wavy  contraction  or  sudden  twitching  of  mus- 
cles, a  variable  degree  of  mental  disturbance,  and  sometimes  accompanied 
by  endocarditis. 

Etiology. — The  disease  is  doubly  more  frequent  in  females  and  the 
ratio  increases  after  puberty.  An  inherited  neurotic  tendency  is  nearly 
always  to  be  traced.  It  rarely  if  ever  affects  the  negro  in  our  country. 
A  rheumatic  tendency  is  often  found  in  the  individual  or  family.  Other 
infections,  as  malaria,  pertussis,  or  scarlatina,  anemia  or  eyestrain, 
sometimes  appear  to  bear  an  etiological  relation  to  it.  The  disease  may 
occur  during  the  first  half  of  pregnancy  or  after  delivery,  particularly  in 
connection  with  puerperal  sepsis.  The  exciting  cause  in  about  20  per 
cent  of  cases  is  fright,  nervous  strain,  or  injury,  and  many  cases  begin 
through  imitation  of  those  affected.  Occasional  epidemics  are  attributed 
to  the  last  of  these  influences.  Sudden  pronounced  barometric  disturb- 
ances with  high  humidity  of  the  atmosphere  are  believed  to  induce  the 
attack  or  a  relapse  in  some  instances. 

Many  writers  have  supported  the  theory  that  the  disease  is  due  to  the 
lodgment  of  an  embolus  in  the  smaller  cerebral  vessels  as  a  result  of 
endocarditis.  WTiile  the  theory  offers  a  plausible  explanation  of  the 
disease,  it  cannot  be  applied  to  all  cases,  for  endocarditis  is  often  absent ; 
and  when  it  is  present,  embolism  is  not  uniformly  found.  A  theory  of 
infection  is  supported  by  some  authors. 

Morbid  Anatomy. — The  changes  which  have  been  most  frequently  found 
in  the  nervous  system  are  congestion,  extravasation,  embolism,  and 
softening.  Hyalin  degeneration  of  cells,  perivascular  exudations  of  leu- 
cocytes, minute  hemorrhages,  and  thrombosis  have  also  been  discovered, 
but  none  of  the  lesions  is  constant.  Simple  or  malignant  endocarditis  is 
often  present. 

Symptoms. — The  disease  may  be  mild  throughout,  or  severe,  even 
maniacal,  and  cases  of  the  former  type  sometimes  develop  into  the  latter. 
In  the  mild  form  only  a  few  groups  of  muscles  may  be  affected,  and  the 
movements  so  slight  as  to  be  discovered  with  difiiculty.  In  many  cases 
there  is  little  more  than  an  inability  to  sit  in  repose  for  more  than  a 
moment  at  a  time.  The  affection  begins  with  twitching  of  the  hands, 
arms,  or  face,  and  soon  involves  the  lower  extremities.  Sometimes  the 
movements  are  unilateral,  often  confined  to  the  right  side ;  or,  beginning 
in  this  manner,  they  may  later  involve  the  other  side  and  become  general. 
They  can  be,  to  a  considerable  extent,  controlled  by  the  will,  and  do  not 
prevent  voluntary  action;  but  they  are  increased  bv  excitement,  fatigue, 
and  imitation,  and  they  are  always  worse  when  the  patient  is  conscious 


ACUTE  CHOREA  68 1 

of  being  observed.  Anemia,  digestive  disturbances,  and  muscular  weak- 
ness are  generally  present,  and  the  patient  often  becomes  fretful,  irri- 
table, and  restless  during  sleep. 

The  severe  form  develops  suddenly  or  follows  a  mild  onset,  and  fre- 
quently manifests  itself  as  a  constant  violent  action  of  all  the  muscles, 
so  violent  in  rare  cases  that  the  patient  must  be  placed  in  a  padded  cell 
(chorea  insaniens),  where  he  pitches  and  tosses  about  like  one  "possessed 
of  many  demons."  Fever  is  often  present.  The  distress  of  the  patient 
is  greatly  aggravated  by  his  inability  to  sleep,  eat,  drink,  or  perform 
any  voluntary  act  of  more  than  a  moment's  duration.  The  voice  is 
affected  and  speech  may  become  impossible.  Between  these  violent  cases 
and  the  mildest  there  is  every  grade  of  severity.  Some  of  the  most 
violent  and  fatal  cases  are  those  occurring  during  pregnancy. 

Cases  have  been  observed  in  which  more  or  less  pronounced  paresis 
existed  with  slight  movements  (paralytic  chorea),  and  monoplegia  or 
paresis  may  persist  after  recovery.  The  affected  muscles  are  often  slightly 
painful  and  tender  to  pressure. 

Heart-murmurs  can  be  heard  in  about  half  the  cases.  In  many  they 
are  significant  of  endocarditis,  but  in  some  cases  they  are  hemic,  due  to 
the  anemia.  The  heart's  action  is  rapid,  but  not,  as  a  rule,  irregular. 
Such  cutaneous  eruptions  as  urticaria,  herpes,  purpura,  and  rarely  sub- 
cutaneous fibrous  nodules,  are  observed. 

Diagnosis. — Few  diseases  enter  into  the  differential  diagnosis  of  chorea. 
Disse?ninated  sclerosis  is  distinguished  by  the  constant  tremor  rather 
than  twitching  of  the  muscles,  the  nystagmus,  and  scanning  speech.  The 
tremor  associated  with  brain-tumors  presents  finer  movements,  and  there 
is  headache  with  focal  symptoms  not  seen  in  chorea.  The  hysterical 
tremor  is  more  uniform,  and  it  is  accompanied  with  other  sensory  and 
motor  symptoms  of  the  disease. 

Prognosis. — Recovery  occurs  in  all  but  the  most  violent  cases.  A 
favorable  prognosis  should  not  be  too  hastily  pronounced,  however, 
owing  to  the  possibility  of  a  mild  case  assuming  a  violent  form. 

Treatment — The  child  should  be  confined  to  bed  in  a  cheerful  room, 
and  quietly  entertained  in  such  manner  as  will  afford  it  the  greatest  rest 
of  body  and  mind.  Too  great  restraint  is  not  profitable;  punishment  is 
injurious.  All  associates  should  be  excluded.  In  a  severe  case  complete 
rest  must  be  afforded  and  potassium  bromid,  with  chloral,  if  necessary, 
should  be  given  in  order  to  reduce  irritability  and  promote  sleep.  Ar- 
senic should  be  given  in  all  cases,  beginning  with  from  one  to  three 
drops  of  Fowler's  solution  and  increasing  a  drop  each  day,  or  less 
rapidly  in  the  case  of  a  young  child,  until  slight  symptoms  of  excess  are 
produced.  It  should  then  be  discontinued  for  a  few  days,  and  resumed  in 
smaller  doses  followed  by  gradual  increase.  The  danger  of  too  prolonged 
use  of  arsenic  must  be  guarded  against.  Hyoscyamin,  physostigmin, 
cimicifuga,  quinin,  belladonna,  the  salts  of  zinc,  and  other  remedies  are 
highly  recommended  by  different  writers.  Strychnin  in  small  doses  is 
useful  as  a  tonic  to  the  muscles.  The  diet  should  consist  of  the  most 
digestible  food  and  the  bowels  should  be  regulated.  The  patient  need 
not  be  confined  to  bed  all  day  after  improvement  has  been  obtained,  but 
he  should  not  be  set  at  liberty  until  all  choreic  movement  has  ceased, 
and  only  moderate  exercise  should  be  permitted  for  several  weeks. 


682  PRACTICE  OF  MEDICINE 

CHOREOID  AFFECTIONS. 

Chronic  chorea  (Huntington's  chorea)  is  a  disease  of  adult  life, 
usually  appearing  after  the  thirtieth  year,  sometimes  inherited,  in  which 
there  is  slow  movement  of  inco-ordination  in  the  hands,  face,  and  legs, 
accompanied  with  progressive  dementia,  and  often  a  suicidal  tendency. 

Hysterical  chorea  is  usually  limited  to  rhythmical  movements  of 
certain  groups  of  muscles,  often  consisting  of  a  constant  nodding  of  the 
head  or,  by  affecting  the  abdominal  muscles,  producing  salaam  swaying 
of  the  body. 

Chorea  major  is  a  form  of  hysterical  chorea  which  was  prevalent  in 
the  Middle  Ages  (St.  Vitus's  or  St.  Anthony's  dance). 

Saltatory  chorea  (latah,  jumpers)  is  probably  also  a  form  of  hys- 
terical chorea  in  which  the  individual  suddenly  springs  forward  when 
he  rests  his  weight  upon  his  lower  extremities,  and  sometimes  utters  a 
sharp  cry.    It  is  extremely  rare  in  this  country. 

Habit  chorea  (habit  spasm)  consists  in  a  frequent,  sudden  movement 
of  one  or  more  groups  of  muscles,  especially  those  of  the  face,  shoulder, 
or  head,  usually  appearing  in  childhood  and  sometimes  persisting 
through  life.  In  some  cases  respiration  is  affected,  producing  sniffling  or 
the  sound  of  hiccough.    It  is  increased  by  excitement  or  fatigue. 

Posthemiplegic  chorea  is  a  jerking  of  paralyzed  muscles  usually  ac- 
companied with  anesthesia  and  contractures. 

Athetosis  (Hammond's  disease)  is  a  form  of  postparalytic  chorea 
consisting  of  rhythmical  movements  of  the  fingers  and  toes,  sometimes 
of  the  mouth.  Contractures  and  subluxations  of  the  phalangeal  joints 
are  sometimes  produced. 

Convulsive  tic  (Gilles  de  la  Tourette's  disease)  is  a  psychosis  of 
neurotic  children  resembling,  if  not  belonging  to,  hysteria.  Irregular, 
sometimes  violent  movements  affect  the  face  and  arms  or  the  entire 
body.  The  seizures  may  be  accompanied  with  an  inarticulate  outcry  or 
the  continued  repetition  of  a  sound  or  word  that  is  heard  (echolalia), 
or  of  profane  or  vulgar  language  (coprolalia),  and  actions  may  be 
mimicked  (echokinesis).  In  some  cases  also  there  is  a  fixed  idea  that 
certain  actions  must  be  performed  at  definite  times,  that  some  object 
must  be  touched  or  a  certain  number  counted  before  some  other  act  can 
be  performed  (arithmomania).  The  disease  is  often  persistent,  but 
recovery  sometimes  occurs. 

Complex  tic  is  a  name  applied  to  many  peculiar,  more  or  less  rh3'-th- 
mical  movements  occurring  in  idiots  and  imbeciles. 

Treatment.— The  treatment  of  all  these  conditions  should  begin  early. 
More  can  be  accomplished  b}^  moral  and  hygienic  means  than  with 
medication.  As  in  chorea,  punishment  aggravates  the  condition.  Arsenic 
and  strychnin  should,  as  a  rule,  be  administered. 

CONVULSIONS  OF  CHILDREN. 

INFANTILE  CONVULSIONS,  ECLAMPSIA. 

Definition.— Convnlsive  seizures  like  those  of  epilepsy,  generally  due  to 
reflex  irritation  or  toxemia,  and  sometimes  developing  into  epilepsy. 
Etio/ogy.— There  is  in  many  cases  an  inherited  or  acquired  predisposi- 


CONVULSIONS  OF  CHILDREN  683 

tion  to  convulsive  seizures,  especially  in  the  children  of  neurotic,  epileptic, 
or  drunken  parents. 

The  exciting  causes  are  many:  (i)  Irritation  of  the  nerve-centers  by 
the  toxins  of  the  acute  infectious  diseases,  the  convulsion  replacing  the 
chill  which  occurs  in  adults.  (2)  Aside  from  the  toxemia  developing  in 
the  prodromal  stage  of  the  acute  infections,  the  most  frequent  cause  of 
convulsions  in  young  children  is  probably  gastrointestinal  irritation.  It 
is  impossible  to  say,  however,  to  what  extent  this  irritation  is  obstruct- 
ive and  produced  simply  by  the  irritation  of  the  stomach  and  intestines, 
and  to  what  extent  it  is  due  to  ptomain-poisoning.  Other  forms  of 
intestinal  irritation  capable  of  exciting  convulsions  are  the  presence  of 
improper  food  and  such  foreign  bodies  as  the  intestinal  parasites.  In  the 
absence  of  a  more  definite  cause  the  attack  is  often  attributed  to  teeth- 
ing, phimosis,  heat-eruption,  and  other  peripheral  irritations.  (3)  In- 
tense paroxysms  of  fright,  anger,  crying,  or  coughing,  as  in  pertussis, 
sometimes  produce  convulsions  as  a  result  of  cerebral  congestion.  (4) 
The  malnutrition  and  debility  accompanying  rickets  may  lead  to  con- 
vulsions, but  more  frequently  to  localized  spasms.  (5)  Trauma  and 
exposure  to  heat  are  occasional  causes.  (6)  Organic  disease  of  the 
brain,  and  meningeal  hemorrhage  during  delivery,  occasionally  incite 
convulsions,  but  such  seizures  do  not  properly  belong  to  this  class. 

Symptoms. — The  paroxysm  is  generally  preceded  for  a  few  moments 
by  twitching  of  the  muscles  of  the  face,  often  confined  to  the  lips,  and 
often  accompanied  with  grinding  of  the  teeth  and  spasmodic  swallowing. 
The  convulsion  begins  with  twitching  of  the  fingers.  The  eyes  are  fixed 
in  a  stare,  the  body  becomes  rigid,  respiration  momentarily  ceases,  and 
the  face  becomes  cyanotic.  This  is  followed  by  a  clonic  spasm,  most 
pronounced  in  the  upper  part  of  the  body.  The  hands  and  arms  jerk, 
the  face  is  contorted,  the  head  drawn  back  and  usually  to  one  side.  The 
eyes  are  rotated  upward  or  spasmodically  drawn  to  one  side.  All  the 
movements  are  rhythmical  and  synchronous,  as  if  due  to  the  discharge 
of  an  electric  current.  After  a  few  seconds  or  several  minutes,  relaxation 
ensues,  and  the  child  usually  falls  asleep.  Vomiting  often  occurs  during 
or  after  the  paroxysm,  especially  in  cases  of  engorged  stomach.  Some- 
times the  convulsions  are  more  pronounced  on  one  side  or  they  may  be 
unilateral  throughout.  Fever  is  usually  present.  Death  rarely  occurs 
■except  in  foudroyant  cases  of  infection,  or  when  the  convulsion  is  the 
termination  of  a  chronic  diarrhea,  cholera  infantum,  hydrocephalus, 
meningitis,  or  other  previous  disease.  The  attack  is  often  repeated  in  a 
few  hours,  possibly  in  a  few  minutes.  Frequent  repetitions  may  beget  a 
strong  tendency  to  convulsions  or  a  true  epilepsy. 

Diagnosis. — The  important  element  in  diagnosis  is  to  determine  whether 
the  seizure  denotes  the  onset  of  an  infection.  When  this  is  the  case,  the 
fever  is  usually  higher  and  there  is  sore  throat,  enlarged  lymph-glands,  an 
eruption,  or  other  symptoms  of  a  specific  disease.  Epilepsy  can  generally 
be  excluded  by  the  age  of  the  patient,  the  absence  of  an  aura  or  previous 
attacks,  less  typical  course,  and  the  recognition  of  an  exciting  cause. 

Prognosis. — Death  may  follow  repeated  convulsions  or  the  initial  con- 
vulsion of  a  violent  infection.  Cerebral  hemorrhage  occasionall}^  occurs 
during  the  seizure,  and  the  child  is  left  hemiplegic.  In  a  great  majority 
of  cases,  however,  complete  recovery  occurs. 


684  PRACTICE  OF  MEDICINE 

Treatment — The  paroxysm  should  be  cut  short  by  a  few  inhalations  of 
chloroform,  especially  in  a  case  of  repeated  convulsions,  for  in  this  man- 
ner serious  results  may  be  prevented.  In  the  absence  of  the  drug,  the 
child  should  be  put  into  a  tepid  bath,  the  head  douched  with  cold  water, 
and,  if  the  temperature  be  high,  the  water  should  be  cooled  with  ice  or  by 
the  gradual  addition  of  cold  water.  To  conform  with  popular  custom  a 
tablespoonful  of  mustard  may  be  tied  in  a  rag  and  dropped  into  the 
water.  Friction  should  be  applied  to  the  body  during  the  bath.  Any 
possible  source  of  irritation  should  be  removed.  If  the  seizure  be  due  to 
gastrointestinal  irritation,  an  emetic  should  be  given  and  followed  with 
an  enema.  An  ice-cap  should  be  applied  to  the  head.  If  the  convulsion 
recur,  morphin  should  be  administered  hypodermically  in  the  dose  of 
gr.  i-ioo  to  I-20  (0.0006 — 0.003),  according  to  age,  or  chloral  may  be 
given  by  enema  in  dose  of  gr.  v  (0.30)  or  less.  Following  the  attack, 
the  child  should  be  kept  under  the  influence  of  the  bromids  for  several 
days,  and  other  precautions,  particularly  regulation  of  the  diet,  should 
be  taken  to  prevent  recurrence. 

EPILEPSY. 

FALLING  SICKNESS,  EPILEPTIC  FITS. 

Definition. — A  paroxysmal  disease  manifesting  periodical  attacks  of 
unconsciousness,  with  or  without  convulsions,  which  are  usually  preceded 
by  an  aura  or  warning.  The  principal  types  of  the  disease  are  :  ((2) 
Grand  mal  or  haut  mal,  in  which  the  unconsciousness  is  profound  and  the 
convulsions  violent;  (Ji) petit  mal,  exhibiting  transitory  unconsciousness 
without  convulsions;  (r)  cortical,  parietal,  or  Jacksonian  epilepsy,  con- 
sisting of  localized  spasm  without  loss  of  consciousness;  (^)  psychical 
epilepsy,  or  double  consciousness,  a  state  of  somnambulism  in  which  acts 
of  violence  may  be  committed,  takes  the  place  of  the  convulsion.  Several 
other  types  are  included  by  some  writers,  most  of  which  belong  rather  to 
what  are  termed  epileptiform  convulsions  than  to  the  disease  proper. 

Etiology. — The  disease  usually  begins  before  the  fifteenth  year,  seldom 
before  the  tenth,  and  rarely  after  the  twentieth.  Epileptic  seizures  occur- 
ring in  later  life  are  generally  due  to  cerebral  syphilis,  occasionally  to 
other  forms  of  intracranial  disease.    Sex  is  practically  without  influence. 

Heredity  of  the  disease  cannot  usually  be  traced,  but  a  very  large  per- 
centage of  the  cases  occur  in  families  of  neurotic  type  exhibiting  a  strong 
tendency  to  such  aff'ections  as  neuralgia,  hysteria,  insanity,  chorea, 
drunkenness,  wantonness,  drug  habits,  or  syphilis.  Repeated  intermar- 
riage intensifies  the  family  predisposition. 

Exciting  Causes. — The  most  important  of  these  are  the  acute  infectious 
diseases,  local  diseases  of  the  brain  compressing  the  cortical  layer ;  emo- 
tional disturbance,  particularly  fright,  trauma,  habitual  convulsions; 
profound  malnutrition,  and  reflex  irritation.  In  the  last  group  are  usu- 
ally enumerated  many  influences  which  much  more  frequently  do  not 
excite  the  disease,  as  dentition,  intestinal  worms,  constipation,  adherent 
prepuce,  masturbation,  foreign  bodies  in  the  nose  or  ear,  and  irritation  of 
the  eye.  Osier  records  a  case  cured  by  removal  of  a  retained  testis. 
Epilepsy  is  sometimes  associated  with  arteriosclerosis. 


EPILEPSY  685 

Symptoms.— I.  Grand  Mai.— This  is  the  typical  and  most  frequent  form 
of  the  disease.  In  a  majority  of  cases  the  seizure  proper  is  preceded  by 
a  prodrome  or  premonition  known  as  the  aura.  The  warning  may  be 
given  in  many  ways.  Rarely  it  is  like  a  puff  of  air,  as  the  name  signi- 
fies. More  frequently  there  is  a  peripheral  sensation  of  some  kind,  pain, 
numbness,  tinghng,  or  burning,  starting  in  a  finger,  in  the  hand,  over  the 
region  of  the  heart,  or  most  commonly  of  all  from  the  stomach  or  intes- 
tines (pneumogastric  aura),  and  often  apparently  traveling  toward  the 
head.  It  is  always  the  same  sensation  and  in  the  same  place  in  each 
case.  Psychic  aurse  occur  in  some  cases.  There  is  a  sensation  of  impend- 
ing danger,  a  dreaminess,  or  a  flash  of  light,  an  odor;  a  peculiar  color, 
or  a  definite  object  is  seen  (visual  aura).  Odd  sounds,  a  musical  note, 
or  voices  may  be  heard  (auditory  aura).  The  aura  may  be  followed  by 
a  sudden  cry.  In  many  cases,  however,  the  outcry  is  absent,  or  it  may 
occur  without  the  aura.  The  duration  of  the  aura  is  variable.  In  some 
cases  it  is  but  momentary,  while  in  others  the  patient  is  given  time  to 
prepare  for  the  attack,  even  time  to  walk  to  a  place  of  safety  and  lie 
down.  Cases  have  been  described  in  which  the  fit  could  be  prevented  by 
quickly  wrapping  a  cord  around  the  finger  in  which  it  starts,  but  such 
cases  are  exceptional.  In  some  instances  peculiar  movements  take  the 
place  of  the  aura.  The  patient  may  turn  around  rapidly  or  run  a  short 
distance  at  great  speed  (procursive  epilepsy), 

T/ie  Paroxysm. — The  patient  suddenly  becomes  unconscious  and  falls 
forward.  The  head  and  face  are  thus  often  injured,  and  the  old  epilep- 
tic can  often  be  recognized  by  his  scars,  bruises,  and  nodosities.  The  fit 
consists  of  three  stages,  the  tonic  spasm,  the  clonic  spasm,  and  coma. 

(^)  Tojiic  Spasm. — This  is  usually  momentary  in  duration.  The  body 
becomes  rigid,  the  head  is  drawn  back  and  to  one  side,  there  is  conjugate 
deviation  of  the  eyes,  the  face  is  pale  and  becomes  cyanotic.  The  fore- 
arms, wrists,  and  fingers  are  strongly  flexed  and  the  legs  extended.  Res- 
piration is  arrested  by  the  contraction  of  the  thoracic  muscles. 

(/^)  Clonic  Spasju. — The  rigidity  is  immediately  followed  by  a  fine 
muscular  tremor,  which  rapidly  passes  into  a  coarse  jerking  of  all  the 
muscles,  increasing  in  intensity  and  rapidity  until  the  limbs  are  violently 
thrown  about.  The  face  is  contorted,  the  eyelids  open  and  close,  and  the 
eyeballs  rotate.  The  jaws  participate  in  the  spasm,  and  the  tongue  is  often 
bitten.  Froth  appears  at  the  mouth  and  it  may  be  stained  with  blood. 
The  urine  and  feces  are  sometimes  discharged.  The  duration  of  this  stage 
is  usually  from  one  to  two  minutes.  As  it  passes,  the  convulsive  move- 
ments become  less  pronounced,  and  the  patient  falls  into  a  state  of  coma. 

(r)  The  Coma  is  profound.  All  rigidity  has  passed  away.  The  breath- 
ing is  heavy  and  rapid,  often  stertorous,  and  the  cyanosis  of  the  face 
gives  place  to  congestion.  After  a  few  moments,  as  a  rule,  the  sleep  be- 
comes more  natural,  and  the  patient  can  be  aroused,  but  if  undisturbed 
he  may  sleep  for  several  hours.  When  he  awakes,  the  mind  is  clear  and 
the  recovery  is  complete,  except  for  the  muscular  soreness  and  whatever 
of  injuries  may  have  been  received.  After  the  attack  the  reflexes  are 
generally  increased  and  the  ankle-clonus  may  be  obtained,  but  they  may 
be  diminished  or  absent.  Slight  albuminuria  may  be  induced,  and  a 
large  quantity  of  clear  urine  is  generally  voided.  An  elevation  of  temper- 
ature of  a  degree  or  less  may  be  observed. 


686  PRACTICE  OF  MEDICINE 

The  periodicity  of  the  epileptic  seizures  is  variable.  In  the  beginning" 
the  seizures  may  occur  at  intervals  of  several  weeks  or  months ;  but  as 
the  disease  becomes  more  firmly  established,  they  recur  with  greater  fre- 
quency until  finally  a  day  may  not  pass  without  its  paroxysms.  A  con- 
dition known  as  the  status  epilepticus  is  ultimately  developed  in  some 
cases,  in  which  the  fits  follow  each  other  so  rapidly  that  consciousness 
is  not  regained  in  the  intervals,  a  febrile  state  is  produced,  and  the 
patient  succumbs  to  exhaustion.  The  paroxysms  occur  at  any  time  of 
day  or  night,  in  some  cases  at  a  definite  hour.  They  are  sometimes 
entirely  nocturnal  in  the  beginning,  and  the  disease  may  be  unrecognized 
for  many  months  until  the  injury  of  the  tongue,  bruises  about  the  head 
or  neck,  the  dislocation  of  a  shoulder  or  other  joint,  or  the  fracture  of 
a  limb  leads  to  an  investigation. 

Postepileptic  State. ^.n  a  majority  of  cases,  as  stated,  the  patient 
awakes  fully  recovered  from  the  attack.  Occasionally,  however,  there 
is  a  condition  of  semiconsciousness  or  trance  in  which  acts  may  be  per- 
formed which  the  patient  does  not  recollect  after  the  condition  has 
passed.  Rarely  it  assumes  the  form  of  mania  with  homicidal  propen- 
sity. The  mind  becomes  impaired  in  the  confirmed  epileptic;  thought 
becomes  sluggish  and  the  speech  is  slow  and  drawling,  often  indistinct. 
Hemiplegia  is  rarely  induced  by  the  attack. 

2.  Petit  Mai. — In  petit  mal  or  mild  epilepsy  there  is  momentary  un- 
consciousness without  a  convulsion.  There  is  at  most  a  slight  muscu- 
lar tremor  of  the  face  or  fingers.  The  patient  may  be  seized  at  any 
moment.  In  some  cases  he  suddenly  becomes  pale,  his  eyes  are  momen- 
tarily fixed,  and  he  drops  whatever  may  be  in  his  hands.  If  writing,  the 
seizure  may  be  recorded  by  a  scrawl  of  the  pen.  In  a  moment  con- 
sciousness returns,  and  he  resumes  the  conversation  or  other  employment. 
He  may  not  be  conscious  of  the  lapse  and  his  associates  may  not  ob- 
serve it.  There  is  no  aura,  as  a  rule,  and  rarely  a  cry.  There  may  be 
a  slight  sense  of  vertigo  or  faintness.  The  patient  seldom  falls;  the 
stage  of  coma  and  the  sleep  are  absent,  but  after  repeated  recurrences 
the  paroxysms  often  develop  into  grand  mal.  In  some  cases  a  peculiar 
act  is  performed,  as  rapid  rubbing  of  the  face,  nose,  or  ear,  or  the  patient 
may  begin  rapidly  to  disrobe.  Acts  of  violence  are  sometimes  committed 
in  the  unconscious  state. 

3.  Jacksonian  epilepsy  (cortical,  symptomatic,  or  partial  epilepsy) 
manifests  itself  in  twitchings  of  a  single  group  of  muscles,  as  those  of 
the  face,  arm,  or  leg,  without  loss  of  consciousness.  A  prodromal  numb- 
ness or  tingling  of  part  of  the  area  may  be  felt  before  the  attack,  and 
the  sensation  may  persist  after  it  has  passed.  The  spasm  is  both  tonic 
and  clonic,  and  may  extend  from  the  original  area  to  the  other  muscles 
of  the  face  or  limb.  Like  those  of  petit  mal  the  paroxysms  are  liable,, 
in  the  course  of  months  or  years,  to  lapse  into  typical  epileptic  seizures. 
The  affection  generally  arises  from  irritation  confined  to  a  single  motor 
region  of  the  cortex,  by  a  tumor,  localized  meningitis,  depressed  bone 
the  result  of  fracture,  hemorrhage,  abscess,  or  sclerosis.  The  attacks  are 
sometimes  observed  in  uremia  and  general  paresis  or  after  hemiplegia 
in  children  (posthemiplegic  epilepsy).  The  attack  is  followed  by  local 
paresis,  sometimes  accompanied  with  loss  of  the  sense  of  touch  and  the 
perception  of  heat. 


EPILEPSY  687 

Diagnosis. — The  true  epileptic  fit  can  generally  be  differentiated  from 
epileptiform  convulsions  due  to  other  affections  by  the  typical  course 
of  the  manifestations  in  a  fully  developed  case.  When  the  seizure  is 
preceded  by  a  distinct  aura,  and  consists  of  tonic  spasm  followed  by 
clonic  spasm  lapsing  into  a  deep  coma,  and  accompanied  by  relaxation 
of  the  sphincters,  the  condition  is  clearly  one  of  epilepsy.  When  many 
previous  attacks  have  occurred,  the  diagnosis  is  usually  further  sup- 
ported by  the  presence  of  scars,  bruises,  and  nodes  on  the  scalp  that 
have  been  referred  to.    Nocturnal  fits  are  almost  always  epileptic. 

Uremic  convulsions  can  be  recognized  through  the  condition  of  the 
urine.  A  persistent  small  trace  of  albumin,  with  low  specific  gravity 
and  particularly  the  presence  of  casts,  is  the  usual  condition.  Head- 
ache and  vertigo  are  generally  present  in  these  cases. 

Hysteria  is  rarely  difficult  of  exclusion.  The  symptoms  are  usually 
overacted.  There  is  no  aura,  the  cry  is  prolonged  and  repeated.  The 
patient  never  injures  herself,  but  may  scratch  and  bite  those  about  her. 
Opisthotonos  is  often  present,  but  the  sphincters  are  not  relaxed.  The 
clonic  spasms  are  less  regular  and  more  prolonged.  The  unconscious- 
ness is  well  feigned,  but  coma  is  absent. 

Fai7iting  from  any  cause  and  the  vertigo  of  Meniere's  disease  are  dis- 
tinguished by  the  absence  of  both  aura  and  unconsciousness. 

/"ro^rwos/s.— Complete  recovery  is  occasionally  observed  in  young  sub- 
jects and  in  women,  seldom  in  men,  but  in  a  great  majority  of  cases 
the  disease  is  incurable.  When  death  occurs  during  a  fit  it  is  generally 
due  to  some  accidental  injury,  as  falling  into  fire  or  water,  or  the  ob- 
struction of  the  larynx  by  food.  Remissions  of  many  months  or  years 
are  sometimes  followed  by  a  renewal  of  the  attack.  Cases  due  to  periph- 
eral irritation  are  generally  most  benefited  by  treatment. 

Treatment— The  first  element  in  the  treatment  should  be  a  careful 
investigation  of  the  case,  and  the  removal  of  any  possible  source  or  irri- 
tation. A  diet  should  be  prescribed  which  is  proper  for  the  age  of  the 
patient  and  the  condition  of  his  digestion.  As  a  rule,  meat  should  be 
eaten  sparingly,  and  an  abundance  of  water  should  be  drunk  to  pro- 
mote the  secretions.    The  action  of  the  bowels  must  be  regulated. 

The  best  remedy  for  the  control  of  the  paroxysms  is  potassium  or 
sodium  bromid;  they  may  be  combined.  From  two  to  four  drams  should 
be  administered  daily  in  the  beginning,  and  if  the  attacks  are  not  ar- 
rested, chloral  should  also  be  given.  Bromism  is  generally  induced  with- 
in a  week  or  two,  and  if  it  becomes  excessive,  the  dose  must  be  reduced ; 
but  bromism  is  more  tolerable  than  epilepsy,  and  the  treatment  should 
be  continued  for  a  month  or  longer  in  most  cases.  After  the  seizures 
have  been  prevented  or  greatly  modified,  the  dose  may  be  gradually 
diminished,  but  a  half-dram  (2.0)  of  the  bromid  should  be  given  daily 
for  several  years  afterward.  The  success  of  the  bromid  treatment  lies 
in  the  persistent  use  of  large  doses.  The  acne  eruption  can  be  greatly 
diminished  by  means  of  full  doses  of  arsenic  administered  for  a  few  days 
at  intervals. 

Many  other  remedies  are  employed  independently  or  in  conjunction 
with  the  bromids,  as  valerian,  asafetida,  cannabis  indica,  and  zinc;  but 
they  are  inferior  to  them.  Nitroglycerin  is  beneficial  more  particularly 
in  petit  mal.     It  should  be  given  in  increasing  doses  and  persistently^ 


688  PRACTICE  OF  MEDICINE 

Inhalation  of  amyl  nitrite  immediately  upon  recognition    of  the  aura 
arrests  the  attack  in  some  cases. 

Excellent  results  have  been  obtained  in  the  treatment  of  this  disease 
in  the  epileptic  colonies.  Here  a  case  that  is  of  such  severity  that  home 
employment  is  impossible  is  given  the  benefit  of  outdoor  occupation, 
which  is  infinitely  better  than  idleness.  Surgical  treatment  is  successful 
in  some  cases,  particularly  those  of  the  Jacksonian  type.  Trephining 
has  proved  beneficial  for  a  considerable  time  at  least,  even  in  cases  in 
which  the  operation  was  technically  a  failure. 

TETANY. 

TETANILLA. 

Definiiion. — An  affection  attended  with  paroxysmal  or  continued  bi- 
lateral tonic  spasm  of  the  muscles  of  the  extremities. 

Etiology. — The  frequency  of  the  affection  diminishes  from  infancy  to 
the  twenty-fifth  year,  after  which  it  is  rarely  encountered.  It  is  often 
associated  with  rickets,  sometimes  with  fevers,  especially  typhoid,  and 
occasionally  with  dilatation  of  the  stomach,  pregnancy,  or  lactation, 
and  it  may  follow  chronic  diarrhea  and  other  debilitating  diseases.  It 
has  developed  after  removal  of  the  thyroid  gland.  Epidemics  of  an 
acute  type  (rheumatic  tetany)  have  been  encountered  in  Europe.  The 
disease  is  more  frequent  in  the  winter  season.  The  exciting  cause  is 
probably  an  irritation  of  the  cortical  centers  by  toxins. 

Symptoms. — An  intermittent  spasm  usually  develops,  first  in  the  hands, 
then  in  the  feet.  The  thumbs  and  fingers  are  firmly  flexed  into  the 
palms,  the  distal  phalanges  being  extended  in  some  cases;  the  wrists 
are  bent  upon  the  forearms,  and  the  elbows  are  often  flexed.  The  feet 
are  extended  (the  flexor  muscles  contracted),  and  the  toes  are  adducted. 
Trismus  is  often  developed  later,  and  the  angles  of  the  mouth  are  drawn 
down,  but  the  face  may  entirely  escape.  The  muscles  of  the  eyelids  are 
often  involved,  sometimes  those  of  the  globe,  with  the  production  of 
strabismus.  The  skin  of  the  hands  and  feet  is  usually  tense  and  may 
become  edematous.  Retraction  of  the  head  sometimes  occurs  late  in  the 
disease,  and  the  thoracic  muscles  may  become  implicated,  producing 
dyspnea  and  cyanosis.  The  attack  is  usually  intermittent,  but  it  may 
become  constant  for  a  period  of  two  or  three  weeks.  The  entire  body 
rarely  becomes  rigid.  A  spasm  can  be  induced  as  long  as  the  affection 
lasts  by  pressure  upon  the  affected  extremities,  over  the  nerve-trunks  or 
blood-vessels  (Trousseau's  symptom).  The  excitability  of  the  motor 
nerves  is  greatly  increased  so  that  a  light  tap  over  the  nerve-trunk 
throws  the  supplied  muscles  into  contraction  (Chvostek's  symptom), 
and  the  electrical  excitability  is  also  increased  (Erb).  Fever  develops 
in  the  more  acute  cases. 

Diagnosis. — Few  conditions  are  to  be  differentiated.  The  carpopedal 
spasm  from  severe  gastrointestinal  irritation  or  occurring  in  rachitic 
infants  is  more  transient.  Teta?ius  is  characterized  by  an  earlier  develop- 
ment of  trismus,  the  cause  is  different,  and  the  bacillus  can  be  demon- 
strated. 

Prognosis  is  usually  good,  although  the  cases  sometimes  last  for  sev- 


MIGRAINE  689 

eral  weeks,  and  recurrences  are  not  infrequent.    After  thyroidectomy  the 
disease  is  often  fatal. 

Treatment. — Any  recognized  irritation  must  be  removed.  The  bowels 
should  be  freely  moved  and  kept  regular.  The  diet  must  be  proper 
for  the  age  of  the  infant  and  easily  digestible  for  the  adult.  Hot  baths 
often  relieve  the  spasm  for  a  time.  Some  writers  prefer  cold  douches 
and  an  ice-bag  to  the  spine.  The  reflex  irritability  should  be  reduced 
by  the  free  administration  of  bromids  and  chloral.  Urethane  is  also 
recommended.  The  thyroid  extract  has  been  curative  in  some  cases, 
doubtless  associated  with  atrophy  or  absence  of  the  thyroid  gland,  as 
in  the  cases  reported  by  Stewart.  Massage  and  electricity  have  been 
employed  with  benefit  in  some  cases,  but  they  aggravate  the  spasm 
for  the  time. 

MIGRAINE. 

MEGRIM,  HEMICRANIA,   SICK  HEADACHE. 

Definition. — A  severe  paroxysmal  headache  usually  confined  to  one 
side,  and  associated  with  disturbance  of  digestion  and  disordered  vision. 

Etiology. — The  affection  ordinarily  develops  before  puberty  and  may 
subside  in  later  life,  in  women  after  the  menopause.  It  is  often  distinctly 
hereditary  and  several  members  of  a  family  are  often  affected,  particu- 
larly on  the  female  side.  It  is  often  associated  with  other  neurotic 
affections  in  the  family  or  ancestry.  A  gouty  or  rheumatic  history  is 
also  common.  It  is  often  associated  with  menstrual  disorders  or  ova- 
rian and  uterine  disease.  Fatigue,  excitement,  anxiety,  worry,  and 
other  debilitating  influences  are  operative  in  some  cases. 

The  exciting  cause  is  not  known.  The  attack  often  follows  a  dis- 
turbance of  digestion,  constipation,  or  the  eating  of  some  article  of 
food  that  does  not  "  agree"  with  the  individual.  Some  persons  invaria- 
bly sufi^er  from  it  when  traveling.  Eye-strain,  due  to  astigmatism  or 
uncorrected  errors  of  refraction,  is  a  frequent  cause.  Irritation  of  the 
nose,  throat,  or  ear  has  been  given  as  exciting  it  in  some  instances. 
Autointoxication  is  probably  one  of  the  most  potent  causes,  but  the 
nature  of  it  is  not  known.  An  accumulation  of  uric  acid  or  of  one  or 
more  of  the  xanthin  group  in  the  blood  have  been  urged  as  the  cause 
by  diff'erent  writers.  The  output  of  these  substances  has  been  shown 
to  be  diminished  by  Haig,  Rachford,  and  others,  before  and  during  the 
attack ;  but  their  accumulation  in  the  blood  has  not  been  demonstrated. 
The  exciting  cause  is  probably  not  always  the  same. 

Symptoms. — Prodromal  languor,  drowsiness,  or  visual  disturbances 
occur  in  some  cases,  while  in  others  the  patient  awakes  with  the  head- 
ache or  is  attacked  soon  after  rising  and  without  warning.  The  pain 
is  at  first  confined  to  one  temple,  to  the  forehead  or  the  occiput,  and 
continues  more  severe  in  that  region;  but  it  soon  becomes  general. 
Light  and  sound  aggravate  it.  There  are  sometimes  hemianopia  or 
flashes  of  light,  tinnitus,  and  vertigo,  accompanied  with  nausea,  and  the 
vomiting  of  bile-stained  mucus.  When  the  stomach  is  at  fault,  this  vomit- 
ing aff'ords  relief.  The  pupil  of  the  affected  side,  sometimes  both,  may 
alternately  dilate  and  contract.  Numbness  and  tingling  of  the  tongue 
and  fingers  may  be  complained  of.    The  headache  becomes  violent  and 

44 


690  PRACTICE  OF  MEDICINE 

throbbing,  and  complete  prostration  ensues.  Various  psychical  disturb- 
ances of  excitement  or  confusion  are  sometimes  exhibited.  The  arterial 
tension  is  increased,  particularly  in  such  vessels  as  the  temporal  of  the 
affected  side;  but  the  pulse  is  usually  slow.  The  face  is  at  first  pale, 
but  becomes  flushed  on  the  aff'ected  side.  Constipation  is  usually  pres- 
ent. The  tongue  is  dry  or  pasty,  but  not  always  furred.  Arteriosclero- 
sis sometimes  develops  in  the  temporal  artery  of  the  affected  side  after 
a  long  series  of  attacks.  The  attack  usually  subsides  in  the  course  of 
a  few  hours  or  a  day,  the  patient  then  falls  asleep  and  awakes  greatly 
relieved.  The  recovery  may  not  be  complete,  however,  in  the  worst 
cases  for  two  or  three  days. 

Treatment — The  attack  is  shortened  and  rendered  less  violent  in  most 
cases  by  the  prompt  administration  of  a  saline  cathartic.  An  emetic  is 
sometimes  equally  beneficial.  In  other  cases  greater  relief  is  afforded  by 
such  remedies  as  sodium  salicylate  (gr.  xv;  i.o),  citrated  caffein  (gr.  v; 
0.30),  with  phenacetin  or  acetanilid  (gr.  x;  0.65),  or  hydrobromic  acid 
(gtt.  xv),  repeated  every  two  to  four  hours.  A  cup  of  strong  tea  or 
black  coffee  is  effective  in  some  cases.  Morphin  should  never  be  given, 
for  the  habit  is  almost  invariably  developed  in  this  class  of  patients; 
even  phenacetin  and  the  myriad  of  proprietary  mixtures  of  acetanilid 
often  acquire  a  fascination  that  is  injurious  to  the  general  health.  An 
ice-cap  should  be  applied  to  the  head,  and  a  mustard-leaf  placed  on  the 
nape  of  the  neck. 

An  effort  should  be  made  in  all  cases  to  determine  the  exciting  cause, 
in  order  to  treat  the  condition  intelligently.  As  general  measures,  errors 
in  diet  or  habits  should  be  rectified.  In  many  cases,  abstinence  from 
meat  and  a  diet  consisting  largely  of  fruits  are  beneficial.  Excitement 
and  fatigue  should  be  avoided,  errors  of  refraction  should  be  corrected. 
Any  cause  of  throat  irritation  should  be  removed.  Any  abnormal  condi- 
tion of  the  uterus  or  ovaries  should  receive  treatment,  and  if  an  anemic 
state  of  the  blood  is  revealed,  iron  and  arsenic  should  be  prescribed. 

NEURALGIA. 

Def/n/'f/'on.—A  disorder  of  the  sensory  fibers  of  the  peripheral  or  vis- 
ceral nerves,  the  chief  manifestation  of  which  is  pain.  It  is  not  always 
possible  in  practice  to  adhere  to  a  close  distinction  between  this  true 
neuralgia  and  peripheral  pain  due  to  central  irritation  or  neuritis  affect- 
ing the  nerve  trunks. 

Etiology. — The  affection  is  rare  in  childhood,  except  as  a  result  of 
caries  of  the  teeth.  Women  are  more  commonly  affected  than  men.  A 
hereditary  tendency  to  neurotic  affections  is  generally  to  be  traced.  In 
many  cases  there  is  :  («;)  An  underlying  malnutrition  of  the  nerves  due  to 
anemia,  malnutrition,  pressure,  or  endarteritis;  (/;)  such  affections 
as  chronic  nephritis,  rheumatism,  gout,  or  diabetes,  or  such  poison  as 
alcohol,  lead,  or  arsenic;  (r)  pressure  upon  the  nerve  by  a  tumor 
or  inflammation  in  its  vicinity.  (^)  The  condition  may  be  induced  by 
an  acute  infection,  especially  by  influenza,  sometimes  by  malaria.  (^)  In 
some  cases  no  cause  can  be  discovered  beyond  probable  exposure  to  cold 
(idiopathic  neuralgia).  (/)  Reflex  irritation  from  a  carious  tooth, 
disease  of  the  middle  ear,  the  nose,   sinuses  or  antrum,  eye-strain,  or 


NEURALGIA  691 

that  of  pathological  conditions  in  the  ovaries,  uterus,  or  intestinal 
canal  may  excite  it. 

Symptoms. — Abruptly,  or  after  premonitory  tingling  or  sense  of  dis- 
comfort, an  aching  or  more  severe  pain  develops  which  is  burning,  bor- 
ing, darting,  or  stabbing  in  character,  sometimes  constant,  but  usually 
paroxysmal.  The  skin  of  the  affected  region  may  be  acutely  sensitive, 
and  tender  points  can  be  found  along  the  course  of  the  affected  nerve  at 
the  places  where  it  passes  from  a  deeper  to  a  more  superficial  level.  The 
skin  is  usually  abnormally  cool  or  hot,  as  a  result  of  trophic  disturb- 
ances; it  may  be  edematous,  and  atrophy  and  induration  occur  in  pro- 
tracted cases.  Herpes  often  appears.  Rarely  the  hair  becomes  white  or 
falls  out,  when  the  nerves  of  the  scalp  are  affected.  An  erythema  due  to 
vasomotor  irritation  sometimes  appears.  The  pain  often  shifts  from 
one  nerve  to  another. 

Any  nerve  of  the  body  possessing  sensory  fibers  may  be  involved. 
The  more  important  of  the  resultant  affections  may  be  conveniently 
arranged  under  the  following  groups  : 

1.  Trifacial  Neuralgia  (Ticdouloureux,  prosopalgia). — This  is  a  se- 
vere affection  of  either  or  all  three  branches  of  the  fifth  pair  of  nerves, 
(fl-)  In  the  affection  of  the  ophthalmic  division  the  painful  points  are : 
(i)  The  supraorbital,  just  above  the  supraorbital  foramen;  (2)  the  pal- 
pebral, in  the  upper  lid;  (3)  the  nasal,  on  the  bridge  of  the  nose  at  the 
junction  of  the  bone  and  cartilage;  (4)  the  ocular,  in  the  globe  of  the 
eye;  and  (5)  the  trochlear,  at  the  inner  side  of  the  orbit. 

((^)  In  the  infraorbital  branch,  the  points  are  in  the  infraorbital  or 
malar  region  and  in  the  upper  lip. 

(if)  When  the  third  division  is  affected,  the  painful  points  are,  the 
temporal,  inferior  dental,  sometimes  the  inferior  labial,  rarely  the  lingual 
in  the  side  of  the  tongue. 

Motion  aggravates  the  pain  in  all  of  these  forms.  A  spasmodic  con- 
traction of  the  muscles  (spasmodic  tic)  often  accompanies  the  pain  and 
greatly  increases  the  suffering. 

2.  Neuralgia  of  the  Neck  and  Trunk.— (<a;)  Cervico-ocipital  and  (J?) 
Cervicobrachial. — These  have  been  considered  under  the  heading  of  Neuritis, 
of  the  Cervical  and  Brachial  Plexuses. 

(^)  Intercostal  N'enralgia. — This  is  a  severe  form  of  the  affection  in- 
volving the  intercostal  nerves  and  intensified  by  the  movements  of  res- 
piration. Three  tenderpoints  are  usually  found — one  in  front,  one  in  the 
axillary  region,  and  one  near  the  spinal  column. 

(^)  PJwenic  nem-algia  is  a  rare  form,  manifested  by  pain  along  the 
insertion  of  the  diaphragm,  in  the  neck,  chest,  and  shoulder. 

(i)  Lumbar  neu7-algia  exhibits  pain  in  the  lumbar  region,  extending  to 
the  femoral  region,  or  along  the  crest  of  the  ilium  to  the  groin  and  vulva 
or  scrotum. 

(/)    Coccygodynia. — (See  Neuritis  of  the  Sacral  Plexus.) 

3.  Neuralgia  of  the  Upper  Extremities.— This  affects  the  branches  of 
the  four  lower  cervical  nerves  and  brachial  plexus,  nerves  which  are  much 
more  frequently  the  seat  of  neuritis.  The  pain  is  in  the  arm  and  fore- 
arm, sometimes  in  the  hand  and  fingers.  The  painful  points  are;  a,  the 
axillary,  over  the  brachial  plexus;  b,  the  scapular;  c,  the  shoulder, 
where  the  cutaneous  branch  of  the  circumflex  emerges  from  the  deltoid  y 


692  PRACTICE  OF  MEDICINE 

d,  the  median  cephalic,  at  the  bend  of  the  elbow;  e,  the  external  hum- 
eral about  three  inches  above  the  elbow;  7^  the  superior  ulnar,  over  the 
ulnar  nerve,  between  the  olecranon  and  the  epitrochlea;  g,  the  inferior 
ulnar,  just  anterior  to  the  annular  ligament  at  the  wrist,  and;  h,  the 
radial,  on  the  lower  external  part  of  the  forearm. 

4.  Neuralgia  of  the  Lower  Extremities.— The  sciatic  nerve  is  some- 
times affected,  giving  a  painful  point  midway  between  the  trochanter  and 
the  tuberosity  of  the  ischium.  Neuritis  is  more  common  in  this  nerve, 
however.     (See  Sciatica.) 

Neuralgia  of  the  feet  occurs  in  the  forms  of  pododynia  or  tender  heel, 
metatarsal  and  plantar  neuralgia.  In  addition  to  the  pain  there  may  be 
burning,  itching,  and  local  sweating. 

The  visceral  neuralgias  are  considered  under  the  headings  of  Neuroses 
of  the  Heart,  Stomach,  Intestines,  and  other  organs. 

5.  Herpes  zoster  (shingles,  zona)  is  a  neuralgia  now  generally  re- 
garded as  a  specific  disease  of  the  posterior-root  ganglia,  probably  an 
acute  hemorrhagic  inflammation,  and,  therefore,  not  strictly  a  functional 
condition.  Of  all  so-called  neuralgias  it  appears  to  bear  the  closest 
relationship  with  malarial  infection.  After  the  neuralgic  pain  has  per- 
sisted for  three  or  four  days,  accompanied  with  general  malaise,  an 
eruption  of  small  vesicles  appears  over  the  peripheral  filaments  of  the 
affected  nerve.  Any  of  the  peripheral  nerves  may  be  affected,  the  in- 
tercostals  more  frequently  than  others. 

Diagnosis. — The  differentiation  from  neicritis  is  not  always  an  easy 
one.  The  latter  affection,  however,  is  generally  distinguished  by  greater 
severity,  longer  duration,  less  tendency  to  migrate,  and  a  greater  lia- 
bility to  trophic  and  vasomotor  disturbances.  The  nerve  pain  pro- 
duced by  cranial  and  spinal  tumors  or  syphilis,  caries  of  the  vertebrae, 
and  the  crises  of  locomotor  ataxia  are  generally  more  permanent,  more 
restricted  in  location,  and  accompanied  by  other  symptoms  of  the  causal 
disease. 

Prognosis. — With  the  exception  of  tic  douloureux,  sciatica,  and  cases 
due  to  organic  disease  which  cannot  be  removed,  the  prognosis  is  good, 
but  recurrences  are  by  no  means  exceptional. 

Treatment.— The  treatment  consists  in  relief  of  the  attack,  removal 
of  the  local  or  exciting  cause,  and  the  improvement  of  the  general  con- 
dition which  acts  as  a  predisposing  factor.  The  pain  is  relieved  by  hot 
fomentations,  poultices,  stupes,  sinapisms,  or  embrocations  containing 
menthol.  The  ethyl-chlorid  spray  affords  temporary  relief,  but  cannot 
be  used  continuously.  Linaments  containing  chloroform,  camphor,  aco- 
nite, or  chloral  may  diminish  the  pain,  but  cannot  be  applied  to  the 
face.    Galvanism  and  cauterization  are  often  beneficial. 

Many  internal  remedies  are  recommended.  The  most  active  are  phe- 
nacetin  or  acetanilid  in  doses  of  gr.  x  (0.13);  sodium  salicylate,  gr.  xv 
(i.o);  an  active  tincture  of  gelsemium  in  frequently  repeated  doses  until 
slight  drooping  of  the  eyelids  is  observed;  and  aconite.  This  remedy, 
to  be  effective,  must  be  carefully  pushed  until  tingling  of  the  lips  is  pro- 
duced— often  a  dangerous  limit.  Nitroglycerin  in  full  doses  is  some- 
times of  benefit,  especially  in  trifacial  and  sciatic  neuralgia.  For  vis- 
ceral neuralgia  such  remedies  as  the  compound  spirit  of  sulphuric  ether, 
aromatic    spirit    of  ammonia,    and    chloroform    are   the    most    useful. 


HYSTERIA  693 

Morphin,  chloral,  alcohol,  and  other  habit-begetting  drugs  should  be 
avoided. 

The  removal  of  the  exciting  cause  embraces  the  treatment  of  all  the 
influences  referred  to  under  Etiology,  including  the  removal  of  cicatrices, 
tumors,  and  improvement  of  conditions  which  cannot  be  removed. 

Of  even  greater  importance  is  the  improvement  of  the  general  health 
by  means  of  rest  and  tonics.  Iron  and,  more  particularly,  arsenic 
should  be  given  when  anemia  is  present.  Quinin  in  tonic  doses,  com- 
bined with  iron  or  arsenic  and  strychnin,  rapidly  improves  the  condi- 
tion in  many  cases.  Codliver  oil  is  beneficial  in  malnutrition.  Outdoor 
exercise  is  essential,  and  many  cases  are  greatly  benefited  by  a  trip  to 
the  mountains  or  removal  to  a  dry,  temperate  climate. 

HYSTERIA. 

Definition. — A  psychoneurosis,  or  functional  disorder  of  the  nervous 
system,  in  which  the  perverted  ideas  inhibit  volition  and  master  the 
functions  of  the  body. 

Etiology. — The  disease  is  most  frequent  in  women  between  puberty 
and  the  menopause,  but  it  is  occasionally  met  with  in  children  after 
the  fifth  year;  it  occasionally  persists  into  old  age,  and  it  is  not  infre- 
quent in  men.  It  is  more  prevalent  in  the  Latin  races,  but  occurs  in 
all  others.    The  severe  forms  of  it  are  rare  in  our  country. 

Heredity  is  a  strong  predisposing  factor.  The  disease  occurs  particu- 
larly in  neuropathic  families,  and  often  alternates  with  epilepsy,  insanity, 
alcoholism,  and  drug  habits.  It  is  sometimes  closely  related  to  degen- 
eracy. Consanguinity  intensifies  the  predisposition.  Habits  of  life  and 
education  have  much  to  do  with  bringing  out  the  individual  tendency. 
Pampering  and  petting,  the  yielding  to  whims,  the  gratifying  of  all 
desires,  sympathizing  in  every  childish  sorrow,  the  cultivation  of  a  selfish 
nature,  and  the  too  early  training  in  the  artificial  life  of  society,  all 
•prepare  the  daughters  of  wealth  for  a  leading  role  in  hysteria.  Fortu- 
nately, this  tendency  is  being  to  a  great  extent  counteracted  b}^  a 
greater  devotion  to  outdoor  games  and  instruction  in  calisthenics.  But 
hysteria  is  by  no  means  limited  to  the  higher  classes.  It  is  often  en- 
countered among  the  poor  and  •  overworked  saleswomen  and  working- 
girls,  among  whom  it  is  often  superinduced  by  ovarian  or  uterine  dis- 
eases, sometimes  by  alcoholism  or  drug  habits. 

Exciting  Causes. — Physical  exhaustion  from  overwork  or  sufi'ering, 
worry,  grief,  fright,  fear,  financial  loss,  religious  excitement,  disappoint- 
ment in  love,  sexual  excess,  especially  masturbation,  shock  or  injury  as 
in  railway  accidents  or  witnessing  a  disaster,  and  many  other  influences 
are  capable  of  inducing  the  seizure  in  a  susceptible  person.  Imitation 
is  a  strong  factor  in  some  cases,  and  in  this  sense  the  disease  is  often 
spoken  of  as  contagious.     , 

Symptoms. — The  course  of  the  disease  may  be  divided  into  a  prodro- 
mal, a  convulsive,  and  a  nonconvulsive  stage,  although  many  cases  pur- 
sue a  most  atypical  course. 

I.  Prodromal  Stage. — This  may  be  of  but  a  few  hours'  duration,  or 
it  may  last  for  several  days.  In  it  the  patient  is  despondent  or  rest- 
less and  emotionate.    She  laughs  and  cries  without  occasion,  and  often 


694  PRACTICE  OF  MEDICINE 

complains  of  a  choking  sensation  (globus  h}^stericus)  and  an  inability 
to  swallow,  or  of  pain  and  hyperesthesia,  especially  in  the  breast  or 
ovarian  region,  sometimes  of  numbness  or  anesthesia,  dizziness,  dyspnea, 
or  other  abnormal  sensation. 

2.  Convulsive  Stage. — The  second  stage  follows  abruptly.  The  patient 
may  fall  into  a  more  or  less  violent  convulsion,  usually  with  a  prolonged 
cry,  or  she  may  walk  rapidly  about,  gesticulating  and  screaming.  The 
severity  of  the  seizure  places  the  case  in  either  of  two  classes,  known  as 
hysteria  minor  and  hysteria  major. 

((^)  Hysteria  Minor.— In  this,  the  more  common  form,  the  fall  is 
guarded.  The  patient  sinks  with  dramatic  grace  to  the  floor,  into  a  chair, 
or  across  the  bed;  she  does  not  injure  herself.  She  becomes  apparently 
unconscious,  and  is  usually  seized  with  convulsive  movements,  the  chief 
characteristic  of  which  is  irregularity.  The  arms  are  thrown  about,  they 
may  be  rigid  or  flaccid;  the  trunk  and  pelvis  may  be  brought  into  motion. 
The  screaming  may  be  continued,  especially  if  the  voice  has  been  cultivated, 
or  the  seizure  may  consist  largely  of  violent  respiration.  Its  duration  is 
from  a  few  minutes  to  several  hours.  WTien  it  subsides,  consciousness  re- 
turns, and  the  patient  usually  has  a  pretty  definite  recollection  of  all  that 
has  transpired,  although  she  may  not  admit  it.  In  other  cases  she  sinks 
into  a  semiconscious  stupor,  from  which  she  can  be  aroused  with  diffi- 
culty. After  the  attack,  a  large  quantity  of  clear  urine  of  low  specific 
gravity  is  generally  voided,  and  much  flatus  may  be  expelled. 

(J))  Hysteria  major,  or  hystero-epilepsy,  is  not  often  seen  in  this 
country.  It  is  not  infrequent  in  France.  The  initial  stage  is  much  like 
that  of  the  milder  form,  except  that  the  action  is  more  violent.  The 
patient  often  suffers  from  gastric  disturbance  for  a  few  days;  the  ab- 
domen becomes  distended  with  flatus,  eructations  are  common,  and 
micturition  is  frequent.  Fantastic  acts  of  all  kinds  may  be  performed, 
and  the  patient  finally  becomes  intensely  excited.  Various  symmetrical, 
acutely  sensitive  spots  are  complained  of  or  found  upon  examination, 
over  the  dorsal  vertebrae,  at  points  on  the  abdomen,  and  over  the  ova- 
ries. The  convulsive  seizure  is  described  under  four  stages:  (i)  The 
epileptoid,  in  which  the  paroxysm  resembles  one  of  epilepsy,  but  is  more 
prolonged;  (2)  a  condition  called  by  Charcot  clownism;  (3)  a  state  in 
which  the  patient  assumes  peculiar  attitudes  suggestive  of  certain  passions 
and  may  be  cataleptic;  and  (4)  a  state  in  which,  although  the  patient 
appears  to  have  regained  consciousness,  she  has  hallucinations  or  is  de- 
lirious. She  sees  visions,  communicates  with  absent  persons,  and  makes 
assertions  that  are  false,  with  the  utmost  confidence  in  their  truth.  She 
may  even  become  dangerous  to  her  attendants  through  charges  against 
their  conduct,  a  belief  which  may  cling  to  her  after  she  has  fully  recovered. 

3.  The  nonconvulsive  stage  is  closely  allied  to  malingering,  although 
the  patient  does  not  voluntarily  deceive.  Any  disease  may  be  simu- 
lated, and  the  completeness  of  the  simulation  corresponds,  as  a  rule,  to 
the  patient's  knowledge  of  the  affection,  or  the  possibility  of  imita- 
tion. Paralyses  are  especially  common,  paraplegia  more  so  than  hemi- 
plegia. In  the  latter  affection,  however,  the  face  is  not  usually  involved. 
The  reflexes  are  generally  increased  or  normal.  Aphonia,  retention  of 
urine,  and  monoplegias  are  sometimes  observed.  Paralysis  of  the  sphinc- 
ters does  not  occur.    Atrophy  does  not  follow  the  paralysis,  but  con- 


HYSTERIA  695 

tractures  of  the  various  muscles  are  often  present,  which  disappear  under 
anesthesia.  Tremors,  spasms,  and  inco-ordination  are  frequently  produced. 
Although  the  muscles  retain  their  full  power,  the  patient  is  often  unable 
to  walk  or  stand.  The  so-called  hysterical  joint,  with  swelling,  pain, 
stiffness,  and  contracture  of  the  associated  muscles,  is  often  observed. 

Such  sensory  symptoms  as  formication,  numbness,  heat  or  cold,  and 
other  paresthesias,  with  loss  of  vision,  hearing,  or  smell,  occur  in  some 
cases.  Vasomotor  symptoms  are  also  of  occasional  occurrence,  as  local- 
ized edema,  congestion,  or  cyanosis. 

The  heart's  action  may  be  rapid,  and  palpitation  is  often  complained 
of;  syncope  is  a  frequent  manifestation.  Attacks  of  pseudoangina  are 
met  with,  and  they  are  sometimes  of  almost  daily  occurrence. 

Hysterical  fever  is  one  of  the  most  interesting  phenomena.  In  perhaps 
a  majority  of  the  cases  the  elevation  of  temperature  is  due  to  deception, 
and  the  thermometer  often  runs  to  the  limit  of  its  capacity,  110°  F.  or 
higher;  150°  F.  has  been  recorded.  But  cases  have  been  repeatedly 
observed  by  clinicians  whose  acumen  cannot  be  questioned,  in  which  a 
moderate  degree  of  fever  has  been  more  or  less  persistent  for  a  long 
period.  In  some  instances  few  or  no  other  manifestations  of  hysteria 
were  present,  but  the  patient  was  of  a  neurotic  type. 

Diagnosis. — A  correct  diagnosis  rests  upon  a  close  observation  of  the 
symptoms.  The  gradual  onset,  the  explosive  outburst,  but  above  all 
the  emotional  condition  of  the  patient  and  the  overacting  of  the  sympr 
toms  in  almost  every  instance,  are  generally  sufficient.  In  some  instances, 
however,  the  exclusion  of  the  affections  simulated  is  extremely  difficult. 
The  administration  of  an  anesthetic  often  removes  doubt,  particularly 
in  the  hysterical  paralyses,  contractures  and  joint  affections. 

Prognosis.— The  disease  is  never  fatal,  but  permanent  cure  is  not 
always  obtainable.  The  more  violent  seizures  often  cease  under  treat- 
ment, but  the  emotional  nature  remains,  and  the  nonconvulsive  mani- 
festations are  apt  to  crop  out  independently  or  in  connection  with  any 
undue  excitement  or  illness. 

Treafmenf.— There  is  no  other  disease  in  which  tact  on  the  part  of 
the  physician  is  more  truly  the  key  to  successful  treatment.  Although 
the  patient  is  in  a  sense  malingering,  she  is  not  guilty  of  intent  to  de- 
ceive. To  her  disordered  mind  the  condition  is  one  of  real  and  serious 
illness.  Many  victims  of  hysteria  are  intellectually  and  morally  far 
above  suspicion  of  intentional  deception,  and  they  are  often  greatly 
chagrined  by  the  realization  of  acts  they  have  committed  during  the 
convulsive  seizure  or  in  a  state  of  trance.  The  condition  must  be  treated 
with  a  due  appreciation  of  these  facts.  The  first  essential  for  the  young 
physician  is  to  gain  the  confidence  of  the  patient  and  her  family.  An 
error  of  diagnosis,  a  failure  to  recognize  the  true  condition,  is  fatal  to 
him.  He  should  impress  the  patient  and  attendants  with  the  fact  that 
the  attack  is  not  a  serious  one.  With  a  statement  of  this  fact,  all  the 
members  of  the  family  except  one  should  be  requested  to  retire  from  the 
room.  The  examination  should  be  brief  and  only  sufficiently  thorough 
to  satisfy  the  physician  that  there  is  no  organic  disease  of  consequence 
in  addition  to  the  hysteria.  If  the  patient  refuses  to  answer  questions 
-or  feigns  unconsciousness,  let  her  alone.  By  the  time  the  prescription  is 
written,  her  curiosity  will  probably  predominate,  and  she  will  open  her 


696  PRACTICE  OF  MEDICINE 

eyes  in  a  wild  stare.  She  can  then  be  addressed,  assured  of  speedy  im- 
provement, and  will  probably  reply.  When  this  end  is  reached,  the 
physician  should  retire.  A  peremptory  order  must  be  given,  however, 
after  leaving  the  room  and  out  of  earshot  of  the  patient,  that  she  must 
be  isolated  and  attended  by  but  one  member  of  the  family,  a  friend 
who  is  capable  of  withholding  sympathy,  or,  better,  a  trained  nurse. 
The  word  hysteria  should  not  be  employed,  but  the  family  should  dis- 
tinctly understand  that  the  nervous  condition  of  the  patient  requires 
absolute  rest  and  a  total  lack  of  L<iympathy.  Her  actions  must  be  over- 
looked as  though  they  were  not  seen.  In  many  cases  she  should  be  left 
alone  a  greater  part  of  the  time,  and  in  every  way  impressed  with  the 
idea  that  no  anxiety  is  being  aroused  by  her  condition. 

The  more  severe  cases  are  not  always  so  easily  overcome,  especially 
in  patients  who  have  gone  through  many  previous  attacks  and  have 
therefore  become  more  adept.  In  these,  strategy  must  sometimes  be 
resorted  to.  The  violent  stage  may  often  be  promptly  terminated  b)^  dash- 
ing or  spilling,  as  if  by  accident,  a  glassful  of  icewater  over  the  face  and 
chest  of  the  patient;  the  necessary  change  of  garments  proves  beneficial. 
The  application  of  a  mustard-draught  or  of  a  cloth  saturated  with 
stronger  ammonia  to  the  abdomen,  or  the  ice-pack,  will  often  restore 
consciousness.  The  mere  preparation  of  them  is  often  sufficient  in  future 
attacks.  The  application  of  ammonia  to  the  nostrils  may  break  up  a 
violent  seizure,  but  the  patient  must  not  be  tortured. 

Sodium  or  potassium  bromid  should  be  prescribed  in  doses  of  gr.  xv 
to  XXX  (i.o  to  2.0).  Valerian  or  asafetida  is  often  a  useful  addition. 
A  cathartic  should  generally  be  ordered,  and  the  bowels  should  be  kept 
regular  in  action. 

The  general  treatment  consists  of  measures  to  restore  the  patient's 
confidence  in  herself  and  to  increase  her  self-control.  This  can  be  accom- 
plished by  kind  but  firm  advice  toward  the  regulation  of  the  habits  of 
life  and  measures  for  the  improvement  of  her  health.  Unfortunately,  in 
many  cases  there  are  problems  of  domestic  infelicity  which  are  difficult 
of  solution.  In  ordinary  cases  an  outdoor  life  and  exercise  are  beneficial. 
Strychnin  and  other  tonics  are  often  useful,  but,  as  a  rule,  few  drugs 
should  be  employed.  In  the  chronic  cases,  patients  who  have  been  bed-fast 
for  perhaps  years,  the  Weir  Mitchell  treatment  has  prov^ed  most  successful. 
This  consists  of  a  graduated  milk  diet,  complete  isolation,  rest,  massage, 
and  electricity.  It  can  seldom  be  properly  carried  out  at  home.  The 
patient  is  given  four  ounces  of  skimmed  milk  every  two  hours  for  the 
first  week;  the  milk  may  be  peptonized,  or  Vichy  or  barley-water  may 
be  added  to  it.  The  quantity  is  then  gradually  increased  and  solid  food 
slowly  introduced.  Massage  is  practiced  daily,  at  first  for  twenty  minutes, 
and  gradually  increased.  The  course  requires  about  six  weeks.  Much 
can  be  accomplished  in  many  cases  by  suggestion,  but  hypnotism  has 
generally  proved  harmful. 

NEURASTHENIA. 

NERVOUS  PROSTRATION. 

Definiiion. — An  exhaustion  of  nerve  force  resulting  in  an  impairment 
and  perversion  of  mental  and  physical  functions. 


NEURASTHENIA.  •  697 

Eiiology. — The  disease  is  most  common  during  the  age  of  greatest 
strain,  particularly  from  the  twenty-fifth  to  the  fortieth  year.  Women 
are  oftener  attacked  than  men.  Predisposition  may  be  inherited  or 
acquired.  The  patient  usually  belongs  to  a  neurotic  family ;  the  parents 
have  at  least  been  of  a  nervous  type  or  they  may  have  been  debilitated 
by  alcoholism,  tuberculosis,  or  other  disease.  All  the  influences  mentioned 
under  Habits  of  Life  and  Education  as  related  to  the  Etiology  of  Hysteria 
prepare  the  way  as  well  for  neurasthenia.  Too  constant  devotion  to 
business,  with  disregard  of  exercise  and  other  relaxation,  is  an  important 
factor  in  many  cases,  especially  among  women.  Physical  strain  is  much 
less  potent  than  mental  strain,  the  so-called  mind-fag.  Excessive  idleness, 
on  the  other  hand,  is  the  only  explanation  of  the  condition  in  some 
cases.  The  disease  sometimes  develops  in  those  who  have  lived  for  a  few 
years  in  a  less  exhilarating  climate  than  they  have  been  accustomed  to, 
as  in  those  who  have  removed  from  the  interior  to  the  seacoast  or 
from  the  continent  to  Hawaii.  It  is,  as  a  rule,  a  disease  of  city  life, 
but  cases  occur  in  the  country.  Acute  disease,  as  typhoid  fever  or  in- 
fluenza; organic  disease,  especially  of  the  ovaries  or  uterus;  reflex  irri- 
tation from  the  eyes,  especially  exophoria;  from  the  nose,  throat, 
stomach,  heart,  kidneys,  and  other  organs ;  injury,  particularly  of  the 
spine,  sexual  excesses,  late  hours,  financial  loss,  and  bereavement  are 
often  influential. 

Symptoms. — The  patient  e,xperiences  a  constant  feeling  of  fatigue.  His 
energy  is  exhausted  and  his  reserve  force  has  been  expended.  Every 
application  of  mental  or  physical  energy  produces  a  sense  of  both  mental 
and  physical  weariness.  The  appearance  of  the  patient  usually  corre- 
sponds to  his  condition.  He  generally  becomes  emaciated  and  anemic, 
but  in  some  cases  the  general  appearance  remains  remarkably  good. 
The  disposition  becomes  irritable  and  despondent.  In  his  selfishness  the 
patient  loses  all  regard  for  his  family  and  others.  Introspection  is  a 
prominent  feature  of  most  cases.  The  patient  concentrates  his  mind 
upon  his  condition.  He  soon  arrives  at  the  conclusion  that  he  has  a 
serious  organic  disease  or  that  he  is  on  the  verge  of  insanit}^,  paresis, 
tuberculosis,  or  other  serious  illness,  or  he  may  brood  over  imaginary 
business  reverses  or  losses,  and  in  women  the  condition  often  develops 
into  hysteria. 

Headache,  more  commonly  a  sense  of  pressure  within  the  head,  insom- 
nia, muscular  tremors,  gastric  and  intestinal  indigestion,  are  frequent 
accompaniments  of  the  affection.  In  the  most  severe  cases  the  fears 
('■phobias")  predominate.  The  patient  fears  not  only  disease  and 
calamities,  but  he  dreads  to  be  alone  (monophobia),  or  fears  a  crowd 
and  shuns  all  assemblages  (anthropophobia) ;  he  is  afraid  of  lightning 
and  thunder,  afraid  to  pass  a  high  building,  to  cross  an  open  space,  and 
a  great  many  other  groundless  fears  may  be  entertained.  WTien  the 
disease  becomes  extreme,  the  patient  is  confined  to  bed  and  believes 
himself  unable  to  perform  any  exertion  without  severe  palpitation  and 
dyspnea.  The  mental  condition  becomes  so  distressing  that  he  often 
contemplates  and  may  attempt  suicide.  Various  disorders  of  the  special 
senses  are  sometimes  o'bserved.  The  eyes  become  irritable  (asthenopia). 
Reading  for  a  (ew  moments  is  followed  by  burning  or  an  aching  and 
flashes  of  light. 


698  PRACTICE  OF  MEDICINE 

Spinal  symptoms  are  present  in  many  cases.  The  patient  has  a  weak 
back,  and  a  sKght  exertion  produces  aching  and  a  tired  feehng  in  the 
spine  and  legs.  Tender  points  are  complained  of,  and  may  be  found 
npon  pressure  along  the  spinal  column.  Intercostal  and  visceral  neural- 
gias, especially  in  the  ovarian  region,  are  complained  of,  as  in  hysteria. 

Vasomotor  symptoms  may  be  present.  The  face  is  flushed,  localized 
sweating,  throbbing  of  the  arteries,  abdominal  pulsation,  are  seen,  and 
the  patient  is  often  conscious  of  the  heart-beats.  Displacement  of  organs, 
as  enteroptosis,  nephroptosis,  etc.,  are  associated  with  some  cases.  The 
disease  is  often  separated  by  various  writers  into  many  classes  or  types 
corresponding  to  the  predominance  of  particular  symptoms,  as  cerebral, 
cardiac,  gastric,  sexual,  spinal,  etc. 

Diagnosis. — The  neurasthenic  condition  often  resembles  in  its  clinical 
manifestations  many  other  diseases  which  must  be  excluded  by  careful 
examination,  but,  as  a  rule,  the  mental  state  of  the  patient  is  so  evident 
that  the  diagnosis  rests  between  this  disease,  hysteria,  hvpochondriasis, 
and  possibly  general  paresis. 

In  hypochondriasis  there  is  the  fixed  idea  or  morbid  sensation,  par- 
ticularly a  pain  under  the  ribs.  The  patient  may  be  neurasthenic,  but 
the  delusion  predominates. 

In  hysteria  the  symptoms  are  more  violent,  and  there  is  the  imitation 
of  diseases  rather  than  the  fear  of  them,  or  the  idea  that  they  exist 
when  they  do  not.  A  neurasthenic  patient  may,  however,  become  hys- 
terical at  times,  or  the  condition  may  merge  into  one  of  hysteria. 

General  paresis  may  begin  with  lassitude,  melancholia,  despondency, 
and  tremors  closely  resembling  neurasthenia,  but  the  delusions  soon 
develop  and  there  is  a  feeling  of  exhilaration  rather  than  of  nervous 
exhaustion.  It  should  be  remembered  also  that  the  initial  symptoms  of 
locomotor  ataxia  and  those  of  exophthalmic  goiter  occasionally  resemble 
neurasthenia  for  a  time,  but  the  differentiation  is  not  usually  difficult 
after  thorough  examination. 

Prognosis. — The  results  of  early  treatment  are  generally  good,  but  in 
the  cases  of  long  standing  recovery  is  often  slow  and  recurrences  are 
common. 

Treatment. — The  management  of  this  disease  is  in  many  respects  like 
that  of  hysteria,  but  the  illness  cannot  be  made  light  of.  The  patient 
cannot  be  made  to  believe  that  he  is  not  seriously  ill  or  that  his  disease 
is  to  any  extent  imaginary.  His  complaints  must  be  listened  to  and 
kindly  considered,  but  every  effort  should  be  made  to  divert  his  atten- 
tion from  his  condition  and  to  overcome  the  habit  of  introspection.  In 
a  severe  case  in  which  the  patient  is  confined  to  bed  or  so  weak  as  to 
be  practically  helpless,  the  Weir  Mitchell  treatment,  referred  to  under  the 
Treatment  of  Hysteria,  is  the  most  appropriate.  In  less  severe  cases  it 
may  be  sufficient  to  recommend  an  outdoor  life,  with  recreation  and 
diversion.  Fishing,  hunting,  boating,  games,  driving,  and  horseback 
riding  in  moderation  are  beneficial.  The  patient  should  retire  early  and 
rise  late,  obtaining  from  eight  to  ten  hours  of  sleep.  This  should  be 
secured  without  drugs  if  possible.  Frequent  baths  should  be  adminis- 
tered. Hydrotherapy,  including  the  cold  pack  and"  douches,  especially  the 
Scotch  douch  of  alternating  hot  and  cold  water,  beginning  moderately, 
is  applicable  to  nearly  all  cases,  but  it  cannot  usually  be  effectually 


OCCUPATION  NEUROSES  699 

applied  at  home.  Sea-bathing  benefits  some  cases  in  which  the  weakness 
is  not  too  great,  especially  nervous  cases,  but  patients  who  are  much 
depressed  do  better  in  the  mountains  than  at  the  seashore.  Electricity 
is  often  of  benefit,  directly  and  through  the  psychical  impression,  and  for 
this  reason  the  static  machine  is  especially  valuable. 

A  change  of  environment  hastens  the  cure,  but  the  patient  should  not 
be  permitted  to  travel  alone.  A  congenial  companion  is  essential,  for 
solitude  aff'ords  too  great  an  opportunity  for  introspection.  Nothing  is 
more  important  than  the  removal  of  the  influences  which  have  led  to 
the  breakdown,  and  in  this  regard  every  case  is  peculiar  to  itself.  Idle- 
ness is  more  harmful  than  restful  employment  in  some  cases.  Some  are 
injured  by  even  reading  or  writing,  while  to  others  it  is  a  relief. 

Tonics,  particularly  strychnin  and  iron,  benefit  many  cases  in  the 
beginning,  but  medication  should  be  suspended,  as  a  rule,  as  soon  as  the 
improvement  has  become  well  established.  The  use  of  tea,  coffee,  to- 
bacco, and  stimulants  should  be  abandoned.  When  sleep  cannot  be 
secured  otherwise,  the  bromids,  trional,  or  codein  may  be  employed,  but 
the  more  powerful  opiates  should  be  avoided  and  the  patient  must  not 
be  informed  of  the  nature  of  the  remedies  he  is  taking. 


OCCUPATION  NEUROSES. 
PROFESSIONAL  SPASMS. 

Definition. — An  irregular  involuntary  spasm  of  certain  groups  of  mus- 
cles as  a  result  of  their  constant  action  in  some  habitual  movement  usu- 
ally peculiar  to  the  individual's  occupation. 

Etiology. — The  principal  types  of  the  affection  are  the  writer's  cramp 
or  scrivener's  palsy,  the  telegrapher's  cramp,  pianist's  cramp,  and  the 
milker's  cramp.  Among  writers  and  telegraph  operators  the  cramp  is 
much  more  frequent  in  men;  in  some  of  the  other  forms,  women  are 
about  equally  subject  to  it.  Improper  methods  of  holding  the  pen  or 
key  are  regarded  as  influential  in  many  cases,  but,  aside  from  this,  little 
is  known  of  the  cause.  Many  patients  are  in  robust  health,  without 
neurotic  or  other  taint  or  recognizable  predisposition.  Nothing  is  known 
of  the  pathology  of  the  affection  further  than  that  there  is  probably  a 
fatigue  of  the  cortical  motor  centers  governing  the  movements  of  the 
hands,  which  results  in  loss  of  co-ordination. 

Symptoms. — In  some  cases  the  cramp  comes  on  instantly  when  the 
pen  is  taken  up;  in  others  the  individual  can  write  for  a  few  moments 
before  it  occurs.  There  is  a  violent  spasm  of  the  muscles  of  the  fingers, 
sometimes  accompanied  with  pain  and  tremor,  and  the  pen  is  often 
thrown  forcibly  from  the  hand.  Neuritis  is  sometimes  developed,  and 
there  may  be  a  constant  feeling  of  fatigue  in  the  muscles.  The  fingers 
often  become  hot  and  red  or  purple,  and  the  skin  may  become  glazed  as 
a  result  of  vasomotor  influence.  The  strength  of  the  muscles  is  not 
impaired,  and  the  spasm  is  not  excited  by  other  use  of  them.  The  elec- 
trical excitability  is  often  disturbed  in  cases  of  long  standing. 

Diagnosis. — The  symptoms  are  generall}^  so  characteristic  as  to  render 
the  diagnosis  perfectly  apparent.     Paralysis  agitans,  paresis,  and  other 


700 


PRACTICE  OF  MEDICINE 


central  diseases,  accompanied  with  tremor,  can  usually  be  excluded  with- 
out difficulty. 

Prognosis. — The  prospect  of  recovery  is  poor,  except  through  an  early 
change  of  occupation, 

Treafment. — An  early  change  of  occupation  sometimes  arrests  the 
disease  to  such  an  extent  that  the  individual  can  resume  his  former  em- 
ployment, providing  he  correct  his  method  of  writing  or  hold  his  pen  in 
a  different  manner.  The  disease  seldom  occurs  in  those  who  use  the 
free-hand  method  of  writing,  with  the  elbow  as  the  fixed  point.  Some 
patients  can  prevent  the  cramp  by  using  a  very  large  cork  penholder. 
Other  devices  are  employed  in  the  form  of  hand-rests,  but  they  are  often 
of  no  benefit.  Some  improvement  may  follow  massage  and  cold  douch- 
ing of  the  arm,  galvanism,  and  the  administration  of  strychnin., 

TRAUMATIC  NEUROSES. 
RAILWAY  SPINE. 

TRAUMATIC  HYSTERIA. 

Definition. — A  condition  of  hysteria  or  neurasthenia  resulting  from  the 
shock  sustained  in  railroad  accidents,  fires,  or  explosions,  or  from  wit- 
nessing the  injury  of  others. 

Efiology. — As  stated  in  the  definition,  the  injury  may  be  physical  or 
mental,  but  the  effect  is  the  same.  The  most  pronounced  cases  are 
often  those  in  which  no  lesion  can  be  discovered  or  in  which  it  is  posi- 
tively known  that  no  physical  injury  has  been  received.  These  cases 
are  well  described  by  the  term  "traumatic  hysteria,"  since  the  condition 
is  purely  a  psychosis  or  psychoneurosis.  A  strong  element  in  the  etiol- 
ogy of  many  cases  is  found  in  the  prospect  of  winning  damages  from  a 
corporation.  The  pathology  of  the  condition  is  generally  expressed  in 
such  terms  as  spinal  irritation  or  spinal  anemia,  but  pachymeningitis  and 
degeneration  of  the  pyramidal  tracts  have  been  discovered  after  death  in 
a  few  cases. 

Symptoms. — The  clinical  features  are  those  of  hysteria  or  of  neuras- 
thenia. They  may  develop  immediately,  after  several  days,  or  as  long 
as  two  or  three  weeks.  Pain  and  tenderness  over  the  back  of  the  head 
and  spine  are  complained  of,  and  one  or  more  tender  spots  can  usually  be 
found  upon  pressure.  Numbness,  formication,  or  sensations  of  heat  and 
cold  are  often  felt  in  the  limbs.  Paralyses  sometimes  develop  in  the 
form  of  either  hemiplegia,  paraplegia,  or  monoplegia.  The  sight,  hearing, 
or  other  sense  may  be  impaired. 

Diagnosis. — An  exact  diagnosis  is  important  from  a  medico-legal  stand- 
point, but  it  is  often  extremely  difficult.  The  differentiation  is  to  be 
made  especially  from  organic  disease  of  the  brain  or  cord  and  from 
malingering.  It  is  often  impossible  in  practice  to  make  an  early  differ- 
ential diagnosis  between  the  purely  functional  cases  and  those  in  which 
injury  has  actually  been  received,  and  the  malingerer  is  not  always  read- 
ily detected.  A  great  deal  is  to  be  inferred  from  the  persistence  of  the 
symptoms.  When  due  to  organic  disease  they  are  more  permanent  and 
less  likely  to  be  overlooked  when  the  attention  is  diverted  from  them 
than  when  purely  functional,   and  improvement  is  less  likely  to  occur 


RAYNAUD'S  DISEASE  701 

after  the  fright  and  shock  have  had  time  to  wear  away.  The  mahngerer 
usually  exaggerates  the  symptoms  to  such  an  extent  that  he  can  be 
detected  in  it,  as  when  a  sharp  tendon  reflex  is  produced  by  a  blow  over 
the  tibia,  and  the  tender  spots  are  forgotten  during  conversation. 

Prognosis. — Complete  recovery  is  the  rule,  but  it  may  not  occur  for 
several  months.  It  is  often  very  rapidly  completed  after  the  termination 
of  litigation.     In  cases  of  real  injury,  however,  it  may  be  permanent. 

Treatment. — The  case  is  to  be  treated  as  one  of  neurasthenia  or  hys- 
teria. 

FUNCTIONAL  PARALYSES. 

PERIODICAL  PARALYSIS. 

This  is  a  form  of  general  paralysis  occurring  in  families,  and  trans- 
mitted through  the  maternal  side.  In  some  cases  only  the  arms  and 
legs  are  affected;  in  others,  all  the  muscles  from  the  shoulders  down; 
and  in  a  few  cases  the  muscles  of  the  tongue,  pharynx,  and  neck  have 
been  involved.  The  attack  comes  on  suddenly  or  after  prodromal  ma- 
laise, often  during  sleep  and  when  the  individual  is  in  perfect  health. 
\Vhen  it  begins  gradually,  it  is  generally  complete  within  twenty-four 
hours.  There  are  seldom  sensory  disturbances;  the  cranial  nerves  and 
special  senses  usually  remain  unaffected.  The  reflexes  are  diminished  or 
abolished,  and  the  electrical  excitability  of  both  the  nerves  and  muscles 
is  greatly  reduced  or  lost.  The  temperature  is  normal  or  subnormal, 
and  the  pulse  is  usually  slow.  After  lasting  from  two  or  three  hours 
to  several  days,  the  paralysis  disappears  as  suddenly  as  it  developed. 
After  a  variable  period  of  from  a  few  days  to  several  months,  the  attack 
recurs    The  recurrences  cease,  however,  after  the  fiftieth  year. 

ASTASIA.— ABASIA. 

These  names  have  been  given  to  two  peculiar  symptoms  which  are 
sometimes  observed  as  independent  affections  in  neurotic  subjects;  they 
are  not  infrequently  combined. 

In  astasia  the  patient  is  unable  to  stand,  while  in  abasia  he  is  un- 
able to  walk.  There  may  be  rigidity  of  the  legs,  with  tremor,  or  ataxia; 
or  there  may  be  complete  limpness,  so  that  the  legs  cannot  support  the 
weight  of  the  body,  although  the  strength  of  the  muscles  remains  intact 
when  the  patient  is  in  a  recumbent  position.  The  condition  is  usually 
associated  with  hysteria,  epilepsy,  chorea,  or  intention  psychosis.  Re- 
covery generally  occurs  after  a  variable  length  of  time,  but  recurrences 
are  apt  to  follow.  The  treatment  consists  of  rest,  electricity,  and  other 
methods  employed  in  hysteria. 

VASOMOTOR  AND  TROPHIC  DISORDERS. 
RAYNAUD'S  DISEASE. 

Definition.— K  symmetrical  disorder  of  the  circulation  due  to  vaso- 
motor influence  beginning  as  a  local  anemia  or  syncope  of  the  extrem- 
ities and  passing  into  asphyxia,  followed  by  gangrene. 


702  PRACTICE  OF  MEDICINE 

Etiology. — The  disease  is  more  frequent  in  women  and  children  of  neu- 
rotic type,  but  not  infrequently  affects  men.  Hysteria,  neurasthenia,  epi- 
lepsy, and  other  nervous  affections  are  often  present  in  the  individual 
or  family.     The  attack  often  follows  exposure  to  intense  cold. 

Morbid  A natomy. -~Ra.ynsiud^ s  theory  attributed  the  cause  to  a  spasm 
of  the  vasomotor  constrictors  arising  in  the  centers  of  the  spinal  gray 
matter,  but  these  lesions  have  not  been  observed.  Peripheral  neuritis 
and  endarteritis  obliterans  have  been  found  in  the  affected  extremities. 
The  gangrene  is  usually  superficial,  but  it  may  involve  the  entire  mem- 
ber to  such  an  extent  as  to  produce  spontaneous  amputation. 

Symptoms. — S^ag-e  of  Local  6;7;r(^^.— Following  a  nervous  paroxysm, 
emotional  disturbance  or  exposure  to  cold,  less  frequently  after  a  gas- 
tric derangement,  one  or  more  fingers  or  toes,  occasionally  all  the  fingers 
and  toes,  or  the  hands  with  the  fingers  and  the  feet  with  the  toes,  be- 
come white,  cold,  and  numb  (dead  fingers,  dead  toes).  Rarely  the  tip 
of  the  nose  and  the  lobes  of  the  ears  are  involved.  This  condition 
lasts  only  a  few  hours,  as  a  rule,  but  may  continue  indefinitely.  It  is 
then  followed  by  the 

Stage  of  Asphyxia  or  Engorgement. — The  color  is  restored  as  it  is  after 
a  part  has  been  frozen.  The  vessels  become  engorged  and  the  skin 
is  livid,  intensely  red  or  purple,  often  mottled.  There  is  slight  swelling, 
with  itching  and  burning  pain.  This  condition  occasionally  develops 
primarily.  The  pain  may  be  excruciating,  but  in  some  cases  a  state 
of  anesthesia  is  developed.  After  a  time  the  affection  may  subside,  but 
similar  attacks  then  occur,  as  a  rule,  at  intervals,  for  several  years,  espe- 
cially after  exposure  to  cold.  The  general  health  may  not  be  affected. 
In  some  cases,  however,  a  chill  occurs,  and  a  condition  of  hemoglobine- 
mia,  with  hemoglobinuria,  is  produced.  The  central  artery  of  the  retina 
is  often  contracted  and  the  vision  is  impaired.  Cerebral  symptoms 
sometimes  develop,  varying  from  mental  torpor  with  transient  loss  of 
consciousness  or  mania  to  aphasia  and  a  temporary  hemiplegia. 

Stage  of  Gangrene. — A  dry  gangrene  frequently  follows  the  stage  of 
engorgement,  limited,  as  a  rule,  to  the  tips  or  pads  of  the  fingers  and 
toes,  often  to  a  single  finger  or  toe  of  each  side.  The  affected  part 
becomes  cold  and  dead,  turns  black  and  mummifies.  A  line  of  demar- 
cation soon  forms,  and  the  flesh  sloughs  away  or  the  entire  phalanx  may 
be  amputated  by  a  dry  gangrene.  This  is  followed  by  slow  cicatriza- 
tion, often  resulting  in  deformity  and  ankylosis. 

Diagnosis. — The  disease  is  distinguished  from  the  symmetrical  gan- 
grene of  leprosy,  diabetes,  and  other  affections  by  the  history  of  the 
case  and  the  absence  of  the  symptoms  typifying  these  affections. 

Prognosis. — The  disease  is  rarely  fatal  except  in  feeble  children.  Many 
recurrences  often  take  place,  but  the  patient  usually  succumbs  to  an- 
other disease. 

Treatment. — Prophylaxis  is  important  after  the  first  attack.  The 
patient  should  avoid  exposure  to  cold  and  other  influences  liable  to 
excite  an  attack.  Nitroglycerin  has  been  found  beneficial  in  some  cases, 
but  of  no  benefit  in  others.  After  the  condition  has  developed  the  treat- 
ment is  that  of  chilblains,  elevation  of  the  limb,  and  the  application 
of  dry  dressings.  \\Tien  the  pain  is  severe,  morphin  should  be  adminis- 
tered.    Massage  and  electricity  have  been  found  of  great  benefit  in  some 


ANGIONEUROTIC  EDEMA 


703 


cases.  The  treatment  of  the  gangrene  is  surgical.  Some  writers  advise 
early  amputation,  while  others  oppose  it.  It  is  a  question  which  should 
be  determined  from  the  extent  of  the  gangrene,  the  probability  of  sepsis, 
and  the  condition  of  the  patient. 


ERYTHROMELALGIA. 

RED  NEURALGIA. 

Definition. — A  rare  chronic  vasomotor  disease  manifested  by  painful 
localized  redness  and  swelling  of  the  skin,  usually  affecting  the  heels  or 
balls  of  the  feet,  sometimes  the  entire  foot  and  rarely  the  hands. 

Etiology. — The  disease  has  generally  been  observed  in  young  adult 
males  of  nervous  type  or  following  rheumatism  or  other  febrile  disease. 
It  is  generally  aggravated  by  warm  weather,  but  may  prove  to  be  worse 
in  winter.  The  nature  of  the  affection  is  not  known,  but  it  is  looked 
upon  as  a  vasomotor  disturbance  or  possibly  due  to  neuritis.  Arterio- 
sclerosis has  been  found,  and  it  has  been  suggested  that  the  disease 
may  depend  upon  irritation  of  the  cells  of  the  ventral  horns  of  the 
spinal  cord. 

Symptoms. — The  feet  first  become  extremely  painful,  then,  especially 
after  walking,  they  become  hyperemic  and  swollen.  The  blood-vessels 
are  engorged  and  stand  out  prominently.  Constitutional  symptoms 
are  sometimes  present,  as  headache,  vertigo,  syncope;  and  the  disease 
has  been  associated  with  Raynaud's  disease. 

Treatment. — The  application  of  ice- water  affords  temporary  relief. 
Massage  and  electricity  have  proved  of  benefit  in  some  cases.  The 
constitutional  treatment  with  tonics  is  important.  Excision  of  the 
nerves  supplying  the  part  has  been  followed  by  relief. 


ANGIONEUROTIC  EDEMA. 

Definition. — A  neurosis  characterized  by  recurrent  acute  edema  of  local- 
ized areas  of  the  skin  or  mucous  membranes. 

Etiology. — Young  adult  males  are  most  commonly  affected.  The  dis- 
ease is  often  hereditary,  passing  through  several  generations,  and  it  is 
generally  encountered  in  persons  of  neurotic  temperament.  Its  nature 
is  not  known,  but  it  is  regarded  as  due  to  nervous  action  upon  the 
blood-vessels  or  lymph-channels  through  which  local  accumulation  of 
lymph  is  produced.  The  disease  has  been  associated  with  Raynaud's 
disease  and  erythromelalgia. 

Symptoms. — The  affection  is  generally  strictly  local,  although  gas- 
tric disorders  and  cardialgia  are  sometimes  present.  Hemoglobinuria 
has  been  observed.  The  swelling  begins,  as  a  rule,  in  the  face,  affecting 
the  eyelids,  the  forehead,  or  cheeks,  sometimes  the  backs  of  the  hands 
or  feet,  the  tongue,  throat,  or  genitalia.  The  affected  part  is  generally 
red  and  warmer  than  the  surrounding  skin.  The  swelling  usually  lasts 
for  one  or  two  days  and  subsides,  but  recurrences  are  the  rule;  sometimes 
they  are  daily,  sometimes  at  longer  intervals,  and  different  regions  are 
often  affected  in  succession. 


704  PRACTICE  OF  MEDICINE 

Treatment. — This  is  confined  to  hygienic  measures,  and  the  admin- 
istration of  tonics  to  improve  the  general  physical  and  mental  con- 
dition. 

FACIAL  HEMIATROPHY. 

Definition. — A  slow,  progressive  atrophy  of  the  bones  and  soft  tissues 
of  one  side  of  the  face. 

Etiology. — The  disease  is  rare.  It  has  usually  been  seen  in  girls 
about  the  age  of  puberty;  in  a  few  instances  it  has  developed  in  adults. 
The  cause  is  generally  a  disturbance  of  the  trifacial  nerve,  as  neuritis, 
trauma,  or  compression  by  a  tumor.  Some  writers  attribute  it  to  a 
lesion  of  the  sympathetic.  It  has  been  associated  with  epilepsy,  mi- 
graine, or  neuralgia. 

Symptoms.— The  disease  generally  begins  on  the  left  side  as  a  wasting 
of  the  subcutaneous  tissues  in  a  small  area,  less  frequently  as  a  general 
atrophy.  From  this  spot  it  spreads  to  adjacent  structures,  especially 
the  upper  maxilla,  but  affects  the  muscles  least.  White  spots  and  areas 
of  brownish  pigmentation  appear  along  the  course  of  the  larger  nerves. 
The  hair  is  lost  and  the  teeth  fall  out  on  the  affected  side,  which  is 
sharply  defined  at  the  median  line,  except  in  a  few  cases  in  which  the 
disease  has  been  bilateral.  The  tongue  and  soft  palate  are  usually  in- 
volved and  the  eyeball,  although  not  atrophied,  sinks  into  the  orbit 
on  account  of  the  loss  of  fat.  In  a  few  instances  atrophic  spots  have 
appeared  on  the  arm  and  back  of  the  same  side.  Paresthesia  and  twitch- 
ing of  the  muscles  have  been  observed. 

Diagnosis. — Other  forms  of  unilateral  atrophy  are  readily  distinguished 
by  the  normal  color  of  the  skin,  the  greater  involvement  of  the  muscles, 
and  exemption  of  the  bones. 

The  disease  is  incurable,  but  it  may  remain  stationary  for  many 
years  and  the  health  is  not  impaired.    There  is  no  treatment. 

SCLERODERMA. 

Definition. — A  diffuse  or  localized  induration  of  the  skin,  probably 
a  trophoneurosis. 

Etiology. — The  disease  is  more  frequent  in  young  or  middle-aged 
women,  but  may  affect  men.  Sclerema  neonatorum  is  not  the  same 
affection.  The  cause  is  not  known.  The  disease  is  a  sclerosis  of  the 
connective  tissue,  probably  following  nutritive  changes  produced  by 
alteration  of  the  blood-supply  to  the  skin.  Atrophy  of  the  thyroid 
has  been  associated  in  some  cases. 

Symptoms.— The  diffuse  form  is  less  frequent  than  the  localized.  The 
induration  begins  on  the  extremities  or  face,  sometimes  on  the  chest 
or  back,  and  gradually  extends.  There  is  at  first  a  thickening  of  the 
skin,  which  interferes  with  the  natural  movement,  especially  of  the  face. 
The  expression  is  lost  and  mastication  is  impeded.  When  the  fingers 
are  affected,  they  cannot  be  moved,  and  forced  flexion  may  tear  the 
skin.  The  skin  becomes  adherent  to  the  underlying  tissues.  The  sur- 
face becomes  white,  with  areas  of  pigmentation,  or  there  may  be  diffused 
discoloration.  It  may  be  normal  or  drier.  The  integument  of  the  en- 
tire  body  finally  becomes  involved,    after   which    the    process    remains 


ACROMEGALY 


705 


stationary  form  any  months  or  years.  Spontaneous  recovery  may  oc- 
cur, or  the  skin  may  undergo  atrophy  and  become  dry  and  parchment- 
like. 

In  a  form  of  the  disease  known  as  sclerodactylia  the  fingers,  including 
the  bones,  undergo  atrophy,  becoming  short  and  thick,  glossy,  and  some- 
times pigmented  or  deformed  by  exostoses.  Ulceration  and  gangrene 
may  follow.     Constitutional  symptoms  are  not  present. 

Localized  Form  (Morphea).— Small,  dry,  sometimes  scaly  patches 
appear  asymmetrically  on  the  surface  of  the  skin,  especially  on  the  face, 
neck,  and  chest.  These  patches  become  white,  brownish,  or  purple,  waxy 
or  dull,  firm,  dry,'  inelastic,  and  thick.  They  are  from  a  half-inch  to 
several  inches  in  diameter.  The  hair  falls  and  the  region  may  become 
anesthetic  and  deeply  pigmented  or  ulcerated  in  the  center.  The  spots 
remain  stationary  for  weeks,  months,  or  years,  then  vanish. 

Treatment — Arsenic  has  been  considered  of  benefit,  but  it  is  difficult 
to  estimate  its  value.  Comfort  may  be  afforded  by  hot  baths  and  in- 
unctions of  oil.  The  galvanic  current  has  been  thought  of  benefit.  The 
patient  should  wear  warm  clothing. 

ACROMEGALY. 

Definition.— A  rare  disease  in  which  the*  bones,  especially  of  the  face 
and  extremities,  take  on  an  abnormal  growth. 

Etiology. — The  disease  aff"ects  women  a  little  more  frequently  than  men, 
and  usually  occurs  in  the  third  decade  of  life.  Nothing  is  definitely 
known  of  its  cause.  In  all  cases  examined  after  death  the  pituitary 
body  and  sella  turcica  have  been  enlarged.  From  this  fact  it  has  been 
attributed  to  alteration  of  an  internal  secretion  of  the  pituitary  body. 
It  has  been  referred  also  to  a  persistence  of  an  active  portion  of  the 
thymus.  The  thyroid  gland  has  been  found  enlarged  or  atrophied  in  a 
few  instances. 

Symptoms. — An  enlargement  of  the  fingers  and  toes  is  usually  the 
first  manifestation.  Then  the  head  begins  to  swell.  The  hypertrophy 
affects  both  the  bones  and  soft  parts.  The  hands  are  described  as  spade- 
shaped  or  "battledore  hands";  they  look  fat  and  broad,  and  the  lines 
of  the  palms  deepen.  The  great  toe  is  generally  most  affected.  The 
motion  of  the  hands  and  feet  is  not  always  greatly  impaired.  The  en^- 
largement  of  the  head  affects  chiefly  the  maxillae,  giving  the  face  a 
lengthened  appearance.  The  supraorbital  eminences  are  increased.  In 
some  cases  the  eyelids,  nose,  tongue,  lips,  and  ears  are  greatly  increased 
in  size.  The  growth  of  the  lower  jaw  often  exceeds  that  of  the  upper, 
and  the  teeth  no  longer  articulate.  They  become  widely  separated  in 
both  jaws,  but  remain  firm.  The  enlargement  gives  the  voice  a  deep 
tone.  The  shoulders  become  broad,  and  kyphosis  or  scoliosis  may  be 
produced.  The  enlargement  of  parts  is  generally  symmetrical,  but  ex- 
ceptions have  been  noted.  The  skin  over  the  enlarged  areas  may  be- 
come flabby  and  pigmented,  but  seldom  dry  or  harsh.  The  electric 
excitability  of  the  muscles  is  increased  or  there  may  be  a  reaction  of  de- 
generation. Such  symptoms  as  headache,  somnolency,  loss  of  memory,^ 
imbecility,  dysmenorrhea,  or  amenorrhea,  and  varicms  affections  of 
the  optic  nerve  are  observed  in  some  cases,   but  a  great  diversity  of 

45 


7o6  PRACTICE  OF  MEDICINE 

clinical  manifestations  is  peculiar  to  the  disease.  A  well-marked  ca- 
chexia develops  sooner  or  later.  The  reflexes  and  special  senses,  except 
vision,  remain  normal,  and  sensation  is  not  affected. 

Diagnosis. — The  appearance  of  a  well-marked  case  is  typical,  especially 
the  great  width  of  the  fingers  and  toes,  and  enlargement  of  the  jaws. 

Osteitis  deformans  is  distinguished  by  the  lengthening  of  the  bone'fe 
without  great  increase  of  width,  and  by  the  less  marked  involvement  of 
the  head.  Arthritis  deformans  is  characterized  by  enlargement  of  the 
ends  of  the  bones,  dryness  of  the  joints,  and  pain  upon  motion.  In 
pulmonary  osteoarthropathy  the  enlargement  is  confined  to  the  fingers 
and  toes,  and  there  is  generally  a  history  of  pulmonary  disorder. 

Prognosis. — The  disease  is  progressive,  but  subject  to  long  intermis- 
sions. The  patient  may  live  many  years,  and  death  is  generally  due  to 
another  disease. 

Treatment. — Extracts  of  the  thyroid,  pituitary  body,  and  of  the  lung 
have  been  employed,  but  with  doubtful  success.  The  most  that  can  be 
hoped  is  to  obtain  an  arrest  of  progress. 


RARE  VASOMOTOR  AFFECTIONS. 

Micromegaly  is  attributed  to  disease  of  that  part  of  the  nervous  sys- 
tem which  presides  over  nutrition.  In  it  some  parts  of  the  body  become 
prematurely  enlarged,  and  others  remain  abnormally  small.  Nothing' 
is  definitely  known  of  its  cause. 

Ainhum  is  a  condition  in  which  the  toes,  usually  the  little  toe  of 
one  or  both  feet,  become  enlarged  and  spontaneously  amputated.  It  is 
met  with  chiefly  in  tropical  or  subtropical  countries,  but  has  been  seen 
among  the  negroes  of  the  Southern  States.  A  groove  forms  under  the 
base  of  the  toe,  this  becomes  swollen,  red  or  purple.  The  groove  becomes 
a  line  of  demarcation,  and  the  toe  is  separated  by  a  dry  gangrene.  Some- 
times the  entire  foot  becomes  involved  or  other  toes  may  be  affected. 
An  intense  burning  pain  extends  up  the  leg  in  some  cases;  in  others 
there  is  entire  freedom  from  suffering. 

Hypertrophic  Pulmonary  Osteoarthropathy.— In  this  aff'ection  there  is 
an  enlargement  of  the  hands  and  feet,  including  the  nails,  and  generally 
of  the  distal  half  or  three-fourths  of  the  bones  of  the  forearms  and  legs. 
It  usually  affects  adult  males  and  is  almost  always  associated  with  a 
chronic  pulmonary  affection,  tuberculosis,  empyema,  or  chronic  bron- 
chitis, but  may  occur  without  recognizable  cause. 

Osteitis  Deformans  (Paget's  Disease). — The  bones  become  enlarged 
much  as  in  acromegaly,  but  they  are  at  the  same  time  softened.  As  a  re- 
sult of  this,  the  long  bones  and  the  spine  become  curved  and  are  often 
painful.  The  bones  of  the  head  are  little,  if  at  all,  affected,  and  those  of  the 
face  escape.  The  cause  is  unknown.  The  pathological  condition  is  a  com- 
bination of  rarefying  and  hyperplastic  osteitis.  Some  of  the  Haversian 
canals  are  enlarged,  others  obliterated.  New  lamellae  are  formed.  There 
is  often  an  apparent  relation  between  the  disease  and  the  development  of 
sarcoma  and  carcinoma  in  the  patient.  The  health  generally  remains 
good  and  the  mind  is  not  affected.  No  treatment  has  been  found  of 
anv  benefit. 


RARE  VASOMOTOR  AFFECTIONS  707 

Leontiasis  ossea  is  a  rare  disease,  in  which  the  bones  of  the  head 
and  face,  and  often  the  soft  tissues  of  the  head  and  neck,  take  on  an  ab- 
normal growth.  The  clavicles  and  hands  may  be  affected.  It  begins 
in  early  hfe  and  may  last  indefinitely.  The  cause  is  not  known.  It  has 
been  attributed  to  injury  in  at  least  one  case.  Osteophytic  growths 
may  form  upon  either  table  of  the  skull.  When  upon  the  inner  table, 
they  may  give  rise  to  symptoms  of  tumor.  No  results  have  been  ob- 
tained from  treatment. 

Hydrops  articulorum  intermittens  is  a  rare  affection  of  the  large 
joints,  characterized  by  sudden,  painless  swelling,  which  persists  for  several 
days,  then  subsides.  It  usually  recurs  at  intervals  of  a  few  weeks  for 
several  years.  It  is  thought  to  be  due  to  a  nervous  influence  which  in- 
terferes with  the  circulation  of  the  blood  and  lymph  in  the  vessels  of 
the  joint.  It  occurs  for  the  most  part  in  neurotic  subjects,  and  has  been 
associated  in  a  few  instances  with  angina  pectoris  or  exophthalmic 
goiter. 


PART    III. 

CLINICAL     METHODS     OF     EXAMI- 
NATION. 


Clinical  Methods  of  Examination. 

The  following  pages  are  devoted  to  the  methods  of  chemical  and 
microscopical  examination  applicable  to  clinical  study.  As  far  as  possi- 
ble only  such  methods  are  given  as  can  be  employed  in  general  prac- 
tice, without  the  use  of  apparatus  found  only  in  a  fully  equipped  labora- 
tory. The  student  is  assumed  to  possess  the  elementary  knowledge  of 
the  use  of  the  microscope  and  chemical  apparatus  which  is  now  a  part 
of  the  laboratory  instruction  in  all  medical  colleges. 

EXAMINATION  OF  THE  BLOOD. 

Obtaining  the  Specimen. — Just  as  in  a  surgical  operation,  everything 
to  be  made  use  of  should  be  at  hand  before  this  little  operation  is  un- 
dertaken. The  hemoglobinometer,  pipettes,  hemacytometer,  enough 
slides  and  cover-glasses,  and  the  diluting  fluid  should  be  in  readiness. 
The  puncture  is  generally  made  on  the  posterior  margin  of  the  lobe  of 
the  ear  with  a  small  knife  or  a  Hagadorn  needle.  For  bacteriological 
examination,  however,  a  larger  quantity  of  blood  must  be  secured  from 
a  vein  of  the  arm,  under  strict  antisepsis,  with  a  hypodermic  S3"ringe. 
The  skin  to  be  punctured  is  first  cleansed  with  a  mixture  of  alcohol  and 
ether,  and  the  instruments  must  be  sterilized.  The  puncture  of  the  ear 
should  be  large  enough  to  produce  a  spontaneous  flow  of  several  drops. 
The  first  two  drops  should  be  discarded. 

The  color  of  the  blood  should  be  noted,  although  it  is  perceptibly 
deficient  only  in  extreme  anemia.  The  time  required  for  spontaneous 
coagulation  is  also  important  in  some  cases.  This  is  normally  from 
three  to  four  minutes,  while  in  hemophilia  it  may  be  as  long  as  ten  or 
fifteen  minutes. 

One  specimen  of  blood  should  always  be  examined  fresh  without  dilu- 
tion or  staining.  A  small  fraction  of  a  drop  of  the  blood  is  placed  on 
the  center  of  a  cover-glass  and  spread  into  a  thin  film  upon  the  slide. 
If  the  specimen  is  not  to  be  examined  immediately,  a  circle  of  the  proper 
size  should  be  painted  with  vaselin  upon  the  slide  before  the  cover  is 
inverted  upon  it.  In  this  manner  the  specimen  can  be  kept  for  several 
hours.  From  the  examination  of  the  undiluted  specimen  one  obtains 
an  idea  of  the  size,  form,  and  nucleation  of  the  corpuscles  (Fig.  25), 
the  depth  of  color  in  the  red,  their  rouleaux-formation,  any  apparent 
excess  of  leucocytes,  the  presence  of  fat,  pigment,  or  other  granules, 
bacteria  or  parasites,  and  roughly  of  the  richness  in  fibrin.  The  speci- 
men should  be  examined  both  with  the  }^-inch  objective  and  with  the 
i-i  2-inch  oil-immersion  lens. 

THE   BLOOD-COUNT. 

Enumeration  of  Red  Corpuscles.— The  blood  must  be  diluted  to  pre- 
cisely 100  or  200  volumes  with  Gowers'  solution,  the  formula  of  which  is  : 


PKICTICE  OF  MEDICINE 


Sodium  sulphate 7-5 

Acetic   acid 20.0 

Distilled  water 125.0 

The  diluting  fluid  must  be  kept  free  from  sediment  and  solid  parti- 
cles by  frequent  filtration.  The  dilution  is  made  by  means  of  the  Thoma- 
Zeiss  hemacytometer,  Fig.  26. 

In  counting  the  red  corpuscles,  the  pipette  shown  in  Fig.  2  7,  and  read- 
ily recognized  by  the  figures  loi  at  the  base,  is  employed.  The  tube  S  is 
immersed  in  the  drop  of  blood  flowing  from  the  ear,  and  by  gentle  suc- 
tion through  the  mouthpiece  m  just  enough  blood  is  drawn  in  to  fill 
it  exactly  to  one  of  the  marks,  preferably  to  .05  or  i.    The  tube  must 

c  \^^  '      ^^  J 

_  V. 

c  .   . .  - 

V  -■>'  O^   0  rj  ^    0 

^■'^      ^     /     \  '^^^'-^ 

\  r 

Fig.  25.— Normal  and  pathological  red  and  white  blood-corpuscles,  a,  Normal  red 
corpuscles;  b.  nucleated  red  corpuscles;  c.  lymphocytes;  d,  large  mononuclear;  c', 
transitional  forms  between  c  and  d;  e,  transitional  forms;  c-',  transitional  neutrophiles; 
f,  polymorphous  forms;  g,  eosinophiles;  /?,  myeloc}"tes. 

be  perfectly  clean  and  dry,  and  the  manipulation  rapid  in  order  to  pre- 
vent coagulation  of  the  blood  within  the  tube.  If  too  much  blood  is 
drawm  in,  the  tube  must  be  cleansed  and  dried  before  the  procedure  is 
repeated.  After  the  desired  quantity  has  been  secured,  the  tip  is  quickly 
cleansed  and  immersed  in  the  diluting  fluid.  Suction  is  again  applied 
and  the  fluid  drawn  exactly  to  the  mark  loi.  The  blood  is  thus  diluted 
in  a  definite  ratio.     If  the  tube  ha.s  been  filled  to  the  mark  i,  the  ratio 


EXAMIKATIOX  OF  THE  BLOOD 


713 


is  I  to  100,  and  if  to  only  the  mark  .05,  it  is  i  to  200.  The  latter  ratio 
is  g-enerally  the  better,  hence  it  is  better  to  draw  the  blood  only  to  the 
.05.  The  rubber  tube  is  now  removed,  and  the  tube  is  closed  by  placing" 
the  thumb  and  finger  over  its  ends,  and  shaken  in  order  to  mix  the 
blood  and  diluting  fluid  in  the  chamber  E.    After  this  the  tube  may  be 


Fig.  26. — Thoma-Zeiss  hemacytometer, 

laid  aside  or  transported,  providing  the  ends  be  closed  by  placing  a 
rubber  band  around  it  longitudinally. 

Another  valuable  diluting  fluid  is  that  of  Hayem  : 

Mercuric  chlorid » „ 0.5 

Sodium  sulphate ,      5.0 

Sodium    chlorid „ „ „ 2.0 

Distilled   water , „ .,^00.0 

The  dilution  may  be  made  also  with  either  a  3  per  cent  solution  of 
sodium  chlorid,  or  a  15  to  20  per  cent  solution  of  magnesium  sulphate. 
In  making  the  count,  the  slide  and  ruled  cover-glass  belonging  to  the 
hemacytometer  must  be  used,  and  the  utmost  care  is  necessary  to  have 
all  parts  perfectly  clean,  and  to  secure  exact  coaptation  of  the  surfaces. 


Fig.   27. — Thoma-Zeiss  pipette  for  diluting  red  blood-corpuscles. 

A  low  objective  with  a  high  ocular  generally  gives  the  best  results,  the 
adjustment  being"  so  arrang-ed  that  the  ruled  squares  will  occupy  a  little 
less  than  the  entire  field.  The  illumination  should  be  moderate.  The 
corpuscles  should  then  be  counted  in  a  definite  number  of  squares,  or 
until  about  1,200  have  been  counted.    A  regiilar  order  must  be  followed 


714 


PRACTICE  OF  MEDICINE 


to  avoid  error,  and  it  is  well  to  check  off  the  squares  as  they  are  counted 
on  an  extemporaneous  diagram.  Cells  lying  on  the  lines  should  be 
counted  with  the  square  below  or  to  the  right,  to  avoid  counting  them 
twice.  After  the  count  has  been  completed,  the  number  of  corpuscles 
in  the  cubic  millimeter  is  computed  by  multiplying  the  average  number 
in  each  square  by  4,000,  and  this  by  the  dilution.  The  percentage  may 
then  be  calculated  on  the  basis  of  5,000,000  to  the  cubic  millimeter 
in  normal  blood.  In  women,  however,  the  normal  is  usually  a  little 
lower,  from  4,000,000  to  4,500,000. 

Enumeration  of  Leucocytes. — In  counting  the  leucocytes,  a  lower  dilu- 
tion is  necessary,  as  a  rule,  i  to  lo  or  less.  When  the  leucocytes  ar6 
greatly  in  excess,  however,  as  in  leukemia,  the  count  is  more  readily 
made  in  a  dilution  of  i  to  20  or  even  i  to  50.  The  diluting  fluid  is 
a  0.33  to  0.50  per  cent  solution  of  acetic  acid,  which  dissolves  the  red 
corpuscles.    The  addition  of  a  few  drops  of  a  gentian-violet  solution 

facilitates  the  count  by  stain- 
ing the  leucocytes.  The  tube 
must  be  held  in  a  horizontal 
position  or  closed  with  the 
rubber  band,  for  its  large  cali- 
ber permits  the  escape  of  the 
fluid.  The  manipulation  is  the 
same  in  all  respects  as  in  the 
dilution  of  the  red  corpuscles. 
The  blood  is  drawn  into  the 
tube  exactly  to  one  of  the  di- 
visions, quickly  freed  from 
superficial  blood,  and  the  di- 
luting fluid  is  drawn  in  to  the 
niark  11.  The  computation  is 
made  by  multiplying  the  aver- 
age number  of  leucocytes  in 
each  square  by  4,000,  and  the 
product  by  the  dilution.  In  ex- 
treme leucocy tosis,  the  erythro- 
cyte tube  should  be  employed. 
Estimation  of  Hemoglobin. — The  most  accurate  method  is  that  by 
means  of  the  Fleischl  hemoglobinometer  (Fig.  28).  The  end  of  the  capil- 
lary pipette  accompanying  the  instrument  is  touched  to  the  drop  of 
blood.  As  soon  as  the  tube  is  filled,  its  contents  are  washed  into  the 
compartment  a  with  water  from  a  medicine-dropper  or  pipette.  This 
compartment  is  then  completely  filled  with  water  and  mixed  by  stirring. 
The  upper  surface  of  the  mixture  of  blood  and  water  should  be  slightly 
convex,  care  being  taken  that  there  is  no  overflow  into  the  other  com- 
partment. Compartment  d^  is  filled  with  pure  water.  An  artificial  light 
of  moderate  strength,  as  that  of  a  candle,  is  reflected  through  the  com- 
partments from  the  mirror  S.  The  color  of  the  blood-mixture  is  com- 
pared with  that  of  the  red  glass  slide  KK,  which  is  thinner  cit  one  end 
than  the  other,  and  therefore  lighter  in  color.  It  is  moved  by  the  thumb- 
screw T.  The  percentage  is  read  from  the  scale  PP  at  the  line  M.  The 
•estimate  is  usually  a  trifle  low.    The  accuracy  of  the  observation  is  not 


Fig.  28. — The  Fleischl  hemoglobinometer. 


EXAMINATION  OF  THE  BLOOD  715 

■entirely, complete,  and  the  result  obtained  by  two  observers  is  seldom 
exactly  the  same,  since  the  eye  is  not  capable  of  discriminating  the  deli- 
cate shades  of  color.  The  ratio  of  hemoglobin  to  the  individual  cor- 
puscles may  be  determined  by  dividing  the  percentage  of  hemoglobin  by 
the  percentage  of  the  red  corpuscles  to  the  normal  as  determined  by 
the  blood-count. 

Staining  the  Blood-Specimen.— Staining  is  resorted  to  chiefly  for  the 
purpose  of  facilitating  the  differential  count  of  the  corpuscles,  bringing 
out  nuclei,  granules,  and  other  peculiarities.  Permanent  specimens  may 
be  mounted  in  this  manner. 

A  small  drop  of  blood  is  spread  between  two  covers  in  the  usual 
manner;  the  covers  separated  and  the  smear  allowed  to  dry.  It  is  then 
fixed  by  passing  it  rapidly  through  the  Bunsen  flame  ten  to  twenty 
times,  or  by  immersion  in  (<?)  absolute  alcohol  for  15  to  30  minutes, 
(^)  in  equal  parts  of  absolute  alcohol  and  ether  for  two  hours,  (^)  in  a 
5  per  cent  alcoholic  solution  of  mercuric  chlorid  for  three  or  more  hours, 
followed  by  thorough  washing  and  drying,  or  (^)  a  i  per  cent  alcoholic 
solution  of  formalin  for  one  or  two  minutes.  The  alcoholic  fixing  fluids 
answer  well  for  the  red  corpuscles  and  malarial  parasites,  but  heat  is 
l^etter  when  the  Ehrlich  triple  stain  is  to  be  used. 

Methods. — The  eosin  and  methylene-blue  solution  is  one  of  the  most 
useful  stains.  Its  action  varies,  however,  chiefly  with  the  quality  of  the 
methylene  blue,  and,  like  all  staining  fluids,  it  should  be  tried  and  modi- 
fied until  good  results  are  obtained  with  normal  blood.    The  formula  is  : 

Saturated   alcoholic  solution   nicth}lene  blue 40.0 

5  ])er  rent  solution   cosin   in  70  per  cent  alcohol 20.0 

Distilled   water 40.0 

The  solution   shoLild   be   tiltered  just    before  it   is   used. 

The  cover-glass  smear  should  be  immersed  in  the  solution  at  a  tem- 
perature of  37°  C.  for  24  hours.  The  erythrocytes  are  stained  red,  the 
nuclei  of  either  red  corpuscles  or  leucocytes  blue,  eosinophile  granules  a 
bright  red,  neutrophile  granules  pink,  basophile  granules  blue.  The  ma- 
larial parasites  take  a  pale  blue  stain.  Better  results  are  sometimes 
secured  by  adding  to  50  c.c.  of  this  solution  10  to  15  drops  of  i  per 
cent  acetic  acid. 

Ehrlich  (or  Bioiidi )  Triple  stain — The  formula  for  this  is  : 

Orange  G.   clear  saturated  solution 6.0 

Acid   fuchsin,   clear  saturated  solution 4.0 

Meth)I  peen,  clear    saturated    solution,   added    drop    by    drop, 

constantl)'  shaking  the  mixture 6.6 

Ghcerin 15.0 

Absolute    alcohol lo.o 

Distilled   water i  vo 

The  orange  G,  acid  fuchsin,  and  methyl-green  solutions  must  be  made 
with  rehable  ingredients,  preferably  with  Grubler's,  and  the  solutions 
should  stand  for  several  days  before  mixing.  It  is  better  to  prepare  at 
first  only  a  small  quantity  of  the  triple  solution  in  order  to  test  its 
action,  for  better  results  are  often  obtained  by  slightly  modifying  the 
formula.    After    a   satisfactory   result    has  been  obtained  the  solution 


7i6  PRACTICE  OF  MEDICINE 

can  be  kept  indefinitely.  The  blood-smear  must  be  thoroughly  fixed, 
preferably  by  heat,  as  otherwise  the  stain  often  acts  too  deeply. 

The  solution  may  be  dropped  upon  the  cover-glass  held  in  a  forceps 
and  permitted  to  act  for  5  or  6  minutes,  washed,  dried,  and  mounted  in 
balsam. 

Results. — Erythrocytes,  orange,  varying  in  intensity  with  their  richness' 
in  hemoglobin;  polychromatophile-red  corpuscles,  brownish  or  black; 
nuclei  of  red  or  white  corpuscles,  a  variable  shade  of  blue  or  green; 
neutrophile  granules,  violet  or  reddish  blue ;  eosinophile  granules,  brilliant 
red;  basophilic  granules,  not  brought  out.  The  malarial  parasites  be- 
come distinct,  although  unstained. 

Basophile  Staim. — A  saturated  aqueous  solution  of  methylene  blue  may 
be  applied  to  the  specimen  for  5  to  10  minutes.  The  basophile  granules 
and  nuclei  are  stained  blue.    Another  useful  stain  consists  of: 

Toluidin i.o 

Phenol 5.0 

Distilled  water 95-0 

After  fixing  with  a  mercuric-chlorid  solution,  the  specimen  is  submit- 
ted to  the  stain  for  five  minutes,  washed  in  i  per  cent  hydrochloric  acid 
in  7  o  per  cent  alcohol.    The  nuclei  and  basophiles  are  stained  blue. 

Staining  the  Malaria  Plasmodium.— Spread  the  film  in  the  usual  man- 
ner and  fix  by  gentle  heat  or  in  absolute  alcohol,  then  stain  in  a  i  per  cent 
aqueous  solution  of  eosin  for  five  minutes,  counter-stain  for  five  min- 
utes in  a  saturated  aqueous  solution  of  methylene  blue  or  in  the  Ehrlich 
triple  stain  for  a  half-hour;  wash,  dry,  and  moimt.  The  specimens 
stained  in  the  Ehrlich  triple  stain  may  be  examined  dry.  The  malaria 
parasite  and  the  nuclei  of  the  leucocytes  are  stained  blue;  the  erythro- 
cytes, red,  except  after  the  Ehrlich  stain,  when  they  become  distinct  by 
contrast. 

Whitney's  Method. — Spread  the  film  as  before  and  thoroughly  dry  with 
gentle  heat.    Then  immerse  in  the  following  solution : 

Potassium  bichroinate '2.0 

Sodium  sulphate , i.o 

Distilled  water loo.o 

Add,  while  warm,  enough  mercuric  chlorid  to  saturate,  and  add,  just 
before  using,  5  per  cent  of  nitfic  acid. 

After  allowing  the  specimen  to  remain  in  this  solution  for  20  minutes, 
wash  in  water,  dry  with  cigarette-paper,  and  stain  for  three  minutes 
with  Ehrlich's  triple  stain.    Wash,  dry,  and  mount. 

Plehn's  Method. — Fix  the  smear  in  absolute  alcohol  for  three  to  five 
minutes,  then  stain  five  or  six  minutes  in  the  following  solution : 

Concentrated  aqueous  solution  methylene  blue 60.0 

One  half  per  cent  solution  of  eosin  in  75  per  cent  alcohol. 20.0 

Distilled  water 40.0 

Twenljr  percent  NaOH gtt.  12.0 

After  staining,  wash  in  water  and  mount  in  balsam. 

This  method  is  one  of  the  most  rapid  and  satisfactory  in  use. 


EXAMNATION  OF  THE  BLOOD 


717 


Widal's  Serum  Test.— This  test  is  based  on  Pfeiffer's  agglutination 
reaction.  The  test  is  apphed  thus  :  A  drop  of  fresh  or  dried  blood  from 
the  ear  of  the  patient  is  diluted  with  10,  20,  and  30  or  more  times  the 
quantity  of  distilled  water.  A  drop  of  fresh,  virulent  bouillon  culture  of 
typhoid  bacilli  is  then  added  to  each,  and  the  specimens  are  immediately 
examined  under  the  microscope  in  the  hanging  drop.  The  agglutination 
may  occur  immediately  or  after  ten  or  fifteen  minutes.  The  bacilli 
appear  grouped  together  in  irregular  tufts  of  variable  size  (Fig.  29) 
and  become  motionless.  The  time  at  which  the  reaction  becomes  dis- 
tinct in  the  different  dilutions  should  be  recorded.  In  the  dilution  of 
I  :ro  an  immediate  agglutination  generally  occurs.  It  may  occur  in  a 
dilution  of  i  :5o,  i  :8o,  or  even  higher.  The  absence  of  this  reaction 
throughout  a  disease  may  be  regarded  as  positive  evidence  that  typhoid 
fever  is  not  present,  since  it  has  been  found  in  97.9  per  cent  of  4^879 
cases  collected  by  Brill.  An  agglutination  of  the  typhoid  bacillus  has 
been  obtained  from  the  blood  of  patients  sufi'ering  with  malaria,  typhus, 
miliary  tuberculosis,  cerebrospinal  meningitis,  and  other  acute  infections^ 
but  rarely  in  a  higher  dilution  than  1:5.  A  reaction  obtained  from  a 
/  b 


Fig   29— Uiclal  tebL  foi  t>phoul  fever      1,   Kegc^tne    i5,  partial  reaction;  c,  positive 
reaction      (Nichols  ) 

dilution  of  i  rjo  is,  therefore,  a  positive  demonstration  of  typhoid  fever 
in  nearly  all  cases,  unless  the  patient  has  previously  passed  through  the 
disease,  for  the  blood  often  continues  to  agglutinate  the  bacilli  for  many 
years  after  recovery.  About  half  the  cases  do  not  give  a  positive  re- 
action before  the  beginning  of  the  second  week,  and  about  a  third  of 
the  cases  do  not  give  a  reaction  before  the  early  part  of  the  third  week. 
It  may  appear,  on  the  other  hand,  as  early  as  the  fourth  or  fifth  day. 
Rarely  it  is  first  obtained  in  a  relapse. 


SPECIFIC  GRAVITY  OF  THE  BLOOD. 

Hammerschlag's  Method.— A  mixture  of  chloroform  (sp.  gr.  1.526) 
and  benzin  (sp.  gr.  0.889)  is  prepared  in  such  proportions  that  the 
specific  gravity  of  the  mixture  is  nearly  that  of  the  blood  (1.050  to 
1.060).  A  drop  of  the  blood,  which  must  be  free  from  air,  is  dropped 
upon  the  surface  of  this  mixture.  If  the  drop  sink,  it  is  heavier  than  the 
mixture,  and  chloroform  must  be  added;  if  it  rest  on  the  surface,  it  is 
lighter,  and  benzin  must  be  added.  The  fluids  must  be  thoroughly  mixed 
after  each  addition.  When  the  blood-drop  remains  stationary,  neither 
sinking  nor  rising,  the  specific  gravity  of  the  blood  is  the  same  as  that 


7i8  PRACTICE  OF  MEDICINE 

of  the  mixture,  which  can  be  determined  with  the  urinometer.  This 
mixture  can  be  kept  indefinitely  after  being  used,  the  blood-drop  having" 
been  removed  with  a  pipette. 

BACTERIOLOGICAL   EXAMINATION  OF  THE   BLOOD. 

Bacteria  are  found  in  the  blood  in  such  small  numbers,  as  a  rule,  that 
they  can  be  detected  only  after  cultivation  on  suitable  media.  This  can 
seldom  be  accomplished  without  laboratory  facilities.  The  method  con- 
sists in  flowing  the  blood  removed  from  a  vein  with  a  hypodermic 
syringe  over  the  surface  of  a  blood-serum  and  agar  culture-medium. 
The  culture  must  be  kept  at  a  temperature  of  3  7  °  C.  Plate  cultures  are 
the  most  satisfactory.  Any  growth  that  occurs  may  be  examined  by  the 
usual  methods  of  bacteriological  examination. 

Other  Tests. — Hemoglobinemia. — The  hematocrit  tube  is  filled  with 
blood  and  revolved  rapidly  for  three  minutes  upon  the  centrifuge.  Nor- 
mally the  blood  separates  into  three  portions,  the  erythrocytes  occupying 
about  half  the  space,  leucocytes  a  narrow  band,  and  clear  plasma  the 
other  portion  of  the  tube.  If  free  hemoglobin  be  present,  the  plasma  is 
tinged  with  red. 

Diabetes. — There  are  two  fairly  reliable  tests  of  diabetic  blood.  Brem- 
er's test  consists  in  the  application  of  the  acid  stains.  \^Tiile  in  normal 
blood  these  are  promptly  taken  up  by  the  erythrocytes,  they  have  no 
eff"ect  upon  these  cells  in  diabetic  blood. 

Winiamso7i's  test  consists  in  adding  the  blood  to  a  methylene-blue 
solution.  Diabetic  blood  changes  the  color  to  yellow,  while  normal 
blood  produces  no  change. 

TESTS   FOR  BLOOD. 

Hemin  Test. — Crush  a  small  crystal  of  sodium  chlorid,  or,  better, 
evaporate  a  drop  of  a  0.5  per  cent  salt  solution  on  a  slide,  and  add  to 

it  a  small  particle  of  the  substance  to  be  tested 
in  a  dry  state.  Fluids  should  be  previously 
evaporated  to  dryness  without  scorching. 
Over  these  particles  place  a  cover-glass,  and 
allow  to  flow  under  this  a  drop  of  glacial 
acetic  acid.  Heat  the  specimen  gently  for 
about  a  minute,  adding  more  acetic  acid  as 
Fig    ^o  —Hemin  crvstals.       i^  evaporates.    As  soon  as  a  brownish  stain  is 

produced,  allow  the  specimen  to  evaporate  to 
dr3'ness  and  mount  in  glycerin.  Small  rhomboidal  crystals  of  hemin 
(hematin  chlorid)  are  seen  (Fig.  30)  if  blood  be  present  in  the  speci- 
men. 

Guaiaoum  Test. — To  a  few  cubic  centimeters  of  a  freshly  prepared  tinc- 
ture of  guaiacum  add  half  as  much  hydrogen  peroxid  in  a  test-tube. 
Under  the  mixture  flow,  through  a  tube  or  down  the  side  of  the  test- 
tube,  the  fluid  to  be  tested.  Immediately  or  perhaps  after  ten  or  fifteen 
minutes,  a  blue  ring  appears  at  the  junction  of  the  two  fluids.  Stains 
mav  be  tested  by  this  method  by  first  impregnating  a  piece  of  pure 
filter-paper  with  the  stain  or  a  solution  obtained  from  it  with  distilled 


EXAMINATION  OF  STOMACH-CONTENTS  719 

water,  then  moistening  an  adjoining  portion  of  the  paper  with  the 
guaiacum-hydrogen-peroxid  mixture.  If  blood  be  present  the  blue  line 
is  formed  at  the  junction  of  the  moistened  areas.  It  must  be  remem- 
bered, however,  that  iodin,  iodids,  and  many  other  substances  produce 
this  reaction. 

Blood-Plates. — These  are  irregularly  shaped  bodies  seldom  recognized 
in  the  ordinary  blood  examination.  They  can  sometimes  be  recognized, 
however,  in  a  strictly  fresh  specimen.  To  obtain  this,  a  cover-glass 
should  be  placed  upon  the  slide,  and  a  drop  of  blood  deposited  immedi- 
ately from  the  ear  at  one  edge  of  the  cover.  The  plates  are  highly 
cohesive  bodies  about  half  the  diameter  of  a  red  corpuscle  and  are  usually 
found  clinging  together  in  irregular  masses.  They  are  colorless  and  have 
no  ameboid  movement.    They  may  be  stained,  however,  with  eosin. 

MuUer's  Blood-Dust. — These  are  small,  highly  refractile,  colorless  gran- 
ules from  J^  to  I, a  in  diameter,  or  equal  to  the  finest  fat-droplets,  and 
exhibiting  rapid  molecular  motion,  but  no  independent  motility.  They 
are  insoluble  in  alcohol  or  ether,  and  stain  with  eosin  or  the  triacid 
stain,  but  not  with  osmic  acid.  They  are  best  seen  with  the  Welsbach 
light.     Similar  granules  are  sometimes  seen  in  hydrocele  fluid  and  pus. 

EXAMINATION  OF  STOMACH-CONTENTS. 

The  stomach-contents  should  be  obtained  for  examination  one  hour 
after  a  test-meal,  which  should  be  ingested  in  the  morning  without 
other  food.  The  contents  are  obtained  by  means  of  the  stomach-tube. 
In  conditions  in  which  the  digestion  is  slow,  and  when  the  food  is  re- 
tained in  the  stomach  longer  than  is  normal,  the  stomach  should  be 
washed  out  the  evening  before.  Several  test-meals  have  been  proposed, 
but  those  of  Ewald  and  Boas  are  most  employed. 

Test-Meals. — Ewald's  test-breakfast  consists  of  a  wheat-roll  to  be 
eaten  without  butter,  and  300  to  400  c.c.  of  water  or  weak  tea  without 
sugar. 

Boas's  test-breakfast  consists  of  a  tablespoonful  of  oatmeal  added 
to  a  quart  (liter)  of  water  with  a  little  salt,  and  boiled  down  to  a  pint 
(500  c.c).  The  only  advantage  claimed  for  this  meal  over  that  of 
Ewald  is  that  it  is  free  from  lactic  acid. 

Passing  the  Stomach-Tube.— The  tube  should  be  moistened  with  clear 
water  before  it  is  introduced.  The  patient  should  sit  erect  with  the 
head  thrown  a  little  backward  and  the  mouth  wide  open.  He  should 
be  instructed  to  breathe  regularly  during  the  passage  of  the  tube.  At- 
tempts to  swallow  as  advised  by  many  writers  do  not  always  facilitate 
its  passage  and  often  confuse  the  patient.  The  tip  of  the  tube  is  placed 
against  the  posterior  wall  of  the  pharynx,  and  then  steadily  pushed 
onward  until  the  white  ring  is  about  on  a  level  with  the  incisor  teeth. 
The  first  passage  of  the  tube  is  disagreeable  to  most  patients,  and  it 
may  be  rendered  difficult,  if  not  impossible,  by  the  gagging  that  is  ex- 
cited. Usually,  however,  with  a  little  persuasion  and  by  quick  manipu- 
lation it  can  be  made  to  reach  the  stomach  before  the  patient  becomes 
greatly  alarmed.  The  gagging  and  nervous  excitement  can  be  dimin- 
ished in  many  cases  by  holding  the  end  of  the  tube  in  chopped  ice  until 
it  becomes  thoroughly  cold  before  it  is  introduced.     The  contents    of 


720  PRACTICE  OF  MEDICINE 

tke  stomach  can  generally  be  made  to  flow  by  having  the  patient  con- 
tract the  abdominal  muscles  with  the  glottis  closed,  as  in  straining  in 
the  act  of  defecation.  In  some  cases,  however,  it  must  be  started  by 
means  of  suction  with  the  Politzer  bag,  Or  by  "stripping"  the  tube. 
The  tube  is  held  firmly  between  the  thumb  and  finger  of  the  left  hand, 
while  the  right  thumb  and  finger  are  pressed  firmly,  and  drawn  down 
the  tube  in  such  a  manner  as  to  produce  suction  within  it.  After  the 
flow  has  been  started,  the  tube  is  converted  into  a  siphon  by  holding 
the  external  end  below  the  level  of  the  stomach.  From  50  to  75  c.c. 
of  contents  are  usually  obtained. 

The  stomach-contents  should  be  filtered  through  dry  filter-paper, 
a  process  requiring  considerable  time  unless  a  filter-pump  is  used.  After 
this  the  contents  may  be  examined  for  free  and  combined  acids,  the  di- 
gestive ferments,  the  products  of  digestion,  and  other  ingredients,  if 
desired. 

QUALITATIVE  TESTS. 

Test  for  Free  Acids. — A  few  drops  of  a  i  per  cent  aqueous  solution 
of  Congo-red  are  added  to  a  few  drops  of  the  filtered  stomach-con- 
tents. If  free  or  combined  hydrochloric  acid  or  the  organic  acids  be 
present,  a  dark-blue  or  blackish-brown  color  is  produced,  while  in  a  neu- 
tral or  alkaline  solution  the  red  color  is  imparted. 

Test  for  Kydrochloric  kci&.—Topfers  Test.—Om^  or  two  drops  of  a 
0.5  per  cent  alcoholic  solution  of  dimethylamidoazobenzol  are  added  to 
about  double  the  quantity  of  stomach-contents.  If  hydrochloric  acid 
be  present,  a  bright  red  color  is  produced;  if  it  be  absent,  a  bright  yellow 
is  produced.  The  test  is  sensitive  to  about  o.oi  per  cent  of  the  acid, 
more  minute  traces  yielding  a  brownish  color. 

Boas's   Test.—T\\^  test-solution  consists  of 

Resublimed  resorciia„, ...~ - -...- ..^..,. 5-o 

White  sugar 30 

95  percent  alcohol 100. o 

To  a  few  drops  of  the  gastric  contents  in  a  porcelain  evaporating- 
dish  a  nearly  equal  quantity  of  the  test-solution  is  added.  The  mixture 
is  then  gently  evaporated  over  a  Bunsen  burner.  In  the  presence  of 
hydrochloric  acid  a  rose-red  color  appears  around  the  edge  of  the  mix- 
ture as  it  evaporates;  if  it  be  absent,  a  yellow  or  brownish  color  is 
produced. 

Gilnzhur^s  Test.—TMi^  test  is  now  less  frequently  employed  than  for- 
merly, owing  to  the  instability  of  the  test-solution  and  the  cost  of  the 
ingredients.  The  formula  is:  Phloroglucin  2.0,  vanillin  i.o,  absolute 
alcohol  30.0.  Its  application  and  the  results  are  the  same  as  those  of 
the  Boas  test. 

Test  for  Organic  Acids.— A  small  portion  of  the  gastric  contents  is 
shaken  with  eight  or  ten  times  its  quantity  of  ether  having  a  neutral 
reaction.  The  reaction  of  the  ethereal  extract  is  then  tested  with  litmus- 
paper.  An  acid  reaction  indicates  the  presence  of  organic  acids.  If, 
however,  the  Congo-red  test  fails,  organic  acids  are  not  present. 

Test  for  Lactic  Acid.— The  acid  reaction  obtained  in  the  foregoing 
test  is  usually  due  to  the  presence  of  lactic  acid.    Its  presence  may  be 


EXAMINATION  OF  STOMACH-CONTENTS  721 

more  positively  determined,  however,  by  Uffelmann's  test.  The  test-solu- 
tion is  made  fresh  as  it  is  required  by  adding  a  few  drops  of  a  dilute 
aqueous  solution  of  ferric  chlorid  to  a  2  per  cent  phenol  solution,  and 
diluted  with  water  until  an  amethyst  color  is  obtained.  Two  or  three 
cubic  centimeters  of  the  filtered  stomach-contents  is  added  to  a  like 
quantity  of  this  solution.  In  the  presence  of  lactic  acid  a  bright  lemon 
or  canary  color  is  produced.  In  its  absence  the  amethyst  color  is  re- 
tained or  changed  to  a  gray.  Reacting  to  lactic  acid  alone,  the  test 
is  sensitive  to  about  0.0 1  per  cent,  but  its  accuracy  is  impaired  by  the 
presence  of  hydrochloric  and  other  acids.  This  difficulty  may  be  avoided 
by  applying  the  test  to  the  ethereal  extract  of  the  contents. 

Test  for  Fatty  Acids.— The  simplest  test  for  the  volatile  fatty  acids, 
acetic,  butyric,  etc.,  is  made  by  holding  a  piece  of  moistened  litmus- 
paper  in  the  vapor  arising  from  boiling  gastric  contents  in  a  test-tube. 

Test  for  Pepsin. — The  test  for  pepsin  is  made  by  submitting  small 
fragments  of  egg-albumen,  coagulated  by  boiling,  to  the  action  of  the 
stomach-contents.  If  the  stomach-contents  contain  hydrochloric  acid, 
the  fragments  of  albumen  are  dropped  into  5  or  10  c.c.  of  it  in  a  test- 
tube  and  kept  at  a  temperature  of  37°  C.  If  the  pepsin  be  normal 
in  quantity,  the  albumen  is  completely  digested  and  dissolved  in  six 
or  seven  hours ;  if  it  be  deficient,  the  digestion  is  delayed,  and  if  it  be  ab- 
sent, no  digestion  occurs.  In  case  the  hydrochloric  acid  is  absent  from 
the  gastric  contents,  it  must  be  added  in  the  ratio  of  o.i  to  0.2  per  cent. 

Test  for  Rennet. — A  few  drops  of  the  stomach-contents  are  added  to 
10  or  15  c.c.  of  milk,  and  kept  at  a  temperature  of  37°  C.  If  the  ren- 
net-ferment be  normal,  the  milk  will  coagulate  in  10  or  15  minutes. 
Delayed  coagulation  indicates  deficiency  of  rennet.  When  hydrochloric 
acid  is  absent,  however,  a  few  drops  of  calcium  chlorid  must  be  added 
in  order  to  convert  the  rennet-zymogen  into  active  rennet. 

Test  for  Proteids. — Acid  albumin,  or  syntonin,  is  precipitated  by  ex- 
actly neutralizing  the  filtered  stomach-contents.  An  excess  of  either  acid 
or  alkali  causes  it  to  be  again  dissolved. 

Albumin. — The  acid  albumin  is  first  removed  by  filtration  after  pre- 
cipitation in  the  foregoing  test.  The  filtrate  is  then  boiled  or  other- 
wise tested  for  albumin.  A  cloudiness  or  precipitate  indicates  its  pres- 
ence. 

Albumose  (Propepton). — The  syntonin  and  albumin  are  first  removed 
by  boiling  and  filtering  a  small  quantity  of  the  gastric  contents  (both 
are  thus  thrown  down  without  neutralization) ;  the  filtrate  is  then  al- 
lowed to  cool,  and  it  is  mixed  with  an  equal  volume  of  a  saturated 
solution  of  sodium  chlorid,  and  a  drop  or  two  of  acetic  acid  is  added. 
If  albumose  be  present,  the  fluid  becomes  turbid ;  the  turbidity  disappears 
upon  heating  and  reappears  upon  cooling. 

Pepton. — Albumin,  syntonin,  and  albumose  are  first  removed  by  the 
above  methods.  The  filtrate  is  then  tested  with  the  biuret  test.  A 
purple  or  a  violet  red  color  indicates  the  presence  of  pepton.  For  ac- 
curacy, the  absence  of  albumin  should  first  be  determined  by  means 
of  the  ferrocyanid  test. 

Blood. — Wlien  the  presence  of  blood  cannot  be  determined  by  inspec- 
tion or  by  means  of  the  microscope,  the  hcmin  or  guaiacum  test  may 
be  employed  (p.  718). 

46 


722  PRACTICE  OF  MEDICINE 

Bile. — The  presence  of  bile  can  generally  be  determined  by  the  green 
color  of  the  gastric  contents,  but  a  more  reliable  method  is  the  Gmelin 
nitric-acid-contact  test,  in  which  a  play  of  colors  is  produced,  of  which 
green  is  characteristic. 

Carbohydrates. — A  few  cubic  centimeters  of  Lugol's  solution  of  iodin 
and  potassium  iodid  are  diluted  until  only  a  faint  color  remains.  A  few 
drops  of  the  filtered  contents  are  then  added.  A  blue  color  indicates 
the  presence  of  unchanged  starch;  a  deep  mahogany  brown  indicates 
erythrodextrin.  The  presence  of  sugar  can  be  determined  by  the  usual 
copper  or  fermentation  tests. 

QUANTITATIVE  TESTS. 

Volumetric  analysis  is  employed  in  testing  the  gastric  contents  chiefly 
with  a  view  to  determining  the  total  acidity,  the  acidity  due  to  free  or 
combined  hydrochloric  acid,  and  that  due  to  the  organic  acids.  These 
tests  are  usually  made  by  titration  with  a  decinormal  solution  of  so- 
dium hydroxid  and  a  suitable  indicator — a  solution  by  means  of  which 
the  exact  neutralization  of  the  acidity  can  be  recognized.  The  sodium 
solution  must  be  made  with  the  greatest  accuracy,  and  owing  to  the 
hygroscopic  nature  of  the  salt  it  cannot  be  made  by  weight.  About 
4  grams  of  sodium  hydroxid  must  be  dissolved  in  8  or  g  c.c.  of  dis- 
tilled water,  and  the  solution  tested  with  a  decinormal  solution  of  hy- 
drochloric acid  which  can  be  more  readily  prepared  by  the  specific-gravity 
method,  or  purchased  ready  for  use.  After  the  exact  alkalinity  of  the 
solution  has  been  thus  determined,  sufificient  distilled  water  is  added 
to  reduce  it  to  the  decinormal  standard,  i.e.,  representing  o.i  gram  of 
the  hydroxid  to  the  liter,  or  0.3996  per  cent. 

Determination  of  Total  Acidity.— A  definite  quantity  of  stomach-con- 
tents, as  5  or  10  c.c,  is  placed  in  a  beaker  (a  porcelain  dish  or  capsule 
is  even  better  on  account  of  its  white  color).  To  this  are  added  a  few 
drops  of  I  per  cent  solution  of  phenolphthalein  in  50  per  cent  alcohol  as 
an  indicator.  This  is  then  titrated  with  the  decinormal  sodium-hydroxid 
solution,  drop  by  drop,  from  the  burette,  and  followed  by  agitation  or 
stirring  of  the  mixture  until  a  permanent  pale-pink  color  is  produced. 
The  degree  of  acidity  is  then  determined  by  multiplying  the  quantity  of 
sodium-hydroxid  solution  employed,  expressed  in  cubic  centimeters,  by  its 
acidity,  which  is  100,  and  dividing  the  product  by  the  number  of  cubic 
centimeters  of  the  gastric  contents  tested.  The  normal  acidity  is  gen- 
erally from  40  to  65. 

Determination  of  Free  Hydrochloric  Acid.— To  a  definite  quantity  of 
the  gastric  fluid  add  a,  few  drops  of  a  0.5  per  cent  alcoholic  solution 
of  dimethylamidoazobenzol.  When  HCl  is  present,  a  cherry  or  brownish 
color  is  produced ;  if  it  is  absent,  the  color  is  a  pure  yellow,  and  titra- 
tion is  unnecessary.  To  determine  the  acidity,  the  mixture  is  titrated 
with  the  decinormal  sodium-solution  until  a  permanent,  pure  yellow 
color  is  obtained,  and  the  calculation  is  made  as  in  the  preceding  test. 
Normally  the  acidity  due  to  free  HCl  is  between  40  and  60.  To  deter- 
mine the  percentage  of  the  acidity,  the  degree  should  be  multiplied  by 
.003637. 

Determination  of  Combined  Hydrochloric  Acid.— 77/*?  AHzarifi  Method. 


EXAMINATION  OF  STOMACH-CONTENTS  723 

— The  gastric  fluid  is  titrated  as  before,  using  a  i  per  cent  aqueous  solu- 
tion of  alizarin-sodium-solfonat  as  an  indicator.  When  the  acidity  has 
been  neutrahzed,  a  permanent,  pale  violet  color  is  produced.  The  per- 
centage of  acidity  may  then  be  calculated  as  in  the  preceding  test.  The 
method  lacks  accuracy,  however,  owing  to  the  wide  range  of  almost 
imperceptible  color  that  can  be  produced.  The  more  accurate  tests  are 
not  applicable  to  clinical  work. 

Determination  of  Organic  Acids.— After  the  total  acidity  of  the  speci- 
men has  been  determined,  the  organic  acids  should  be  removed  from 
another  portion  of  the  gastric  filtrate  by  extraction  with  ether.  To 
accomplish  this,  a  portion  of  the  filtrate  is  shaken  with  a  quantity  of 
neutral  ether,  and  the  fluids  allowed  to  separate.  The  gastric  portion 
is  then  shaken  with  another  quantity  of  ether,  and  the  process  is  re- 
peated until  the  gastric  fluid  has  been  extracted  with  eight  or  ten  times 
its  volume  of  ether.  Its  total  acidity  is  then  determined  as  before,  and 
the  difference  in  the  result  represents  the  loss  occasioned  by  the  removal 
of  the  organic  acids. 

Determination  of  the  Fatty  Acids.— Since  the  fatty  acids  are  volatile, 
they  can  be  removed  by  heat.  After  the  total  acidity  has  been  deter- 
mined, another  definite  quantity  is  thoroughly  boiled,  and  the  fluid  lost 
by  evaporation  is  replaced  by  the  addition  of  water.  The  total  acidity 
is  again  determined  by  titration,  and  the  loss  represents  the  degree  of 
acidity  due  to  the  fatty  acids. 

Determination  of  Lactic  Acid.— The  degree  of  acidity  due  to  lactic 
acid  is  represented  by  the  difference  between  the  total  acidity  due  to 
organic  acids  and  that  due  to  fatty  acids.  If  fatty  acids  be  absent,  the 
acidity  due  to  lactic  acid  represents  the  total  organic  acidity.  To  de- 
termine the  percentage  of  lactic  acidity,  multiply  the  degree  by  .008979. 

MICROSCOPIC  EXAMINATION. 

This  examination  is  generally  of  minor  importance,  owing  to  the 
almost  constant  presence  of  a  great  variety  of  unimportant  substances. 
For  the  examination,  a  small  mass  of  the  solid  matter  left  in  the  filter 
should  be  picked  up  on  the  platinum  loop,  spread  on  a  slide,  and  ex- 
amined with  low  and  medium  power.  After  the  Ewald  breakfast  the  field 
is  largely  made  up  of  starch-granules.  These  can  be  more  distinctl}^ 
brought  out  by  passing  a  drop  of  dilute  iodin  solution  under  the  cover- 
glass.  Other  substances  commonly  seen  are  fragments  of  other  undi- 
gested food,  fat-globules,  crystals  of  fatty  acids,  erythrocytes,  leucocytes, 
various  micro-organisms,  and  sometimes  leucin,  tyrosin,  or  cholesterin 
crystals  from  the  intestine.  The  bacteria  may  be  stained  in  the  usual 
way,  or  cultures  may  be  made  in  order  to  differentiate  the  varieties. 
Fragments  of  solid  tissues  may  be  hardened  and  cut  for  histological 
examination. 

EXAMINATION  OF  THE  STOMACH-CONTENTS  AFTER  FASTING. 

This  examination  is  sometimes  desirable  in  order  to  determine  the 
presence  of  superacidity  and  its  character.  The  stomach  must  be  washed 
out  and  emptied  the  evening  before.  No  food  or  drink  is  then  taken 
until  the  stomach-contents  have  been  obtained  with  the  stomach-tube 


724  PRACTICE  OF  MEDICINE 

in  the  morning.  If  the  quantity  obtained  exceed  60  c.c,  there  is  super- 
secretion.  The  percentage  of  acidity,  pepsin,  and  rennet  may  then  be 
determined  by  the  methods  that  have  been  given. 

EXAMINATION  OF  STOMACH-WASHINGS. 

The  chief  importance  of  this  is  in  cases  of  suspected  poisoning.  It 
is  best  in  such  cases,  if  possible,  to  secure  some  of  the  stomach-con- 
tents before  lavage ;  otherwise,  the  water  must  be  examined  for  the  vari- 
ous poisons.  If  the  examination  is  to  be  made  by  a  chemist  with  a 
view  to  criminal  prosecution,  the  specimen  should  be  placed  in  a  clean 
bottle,  securely  sealed,  and  marked  in  some  manner,  as  by  pasting  a 
strip  of  paper  over  the  stopper  and  neck  of  the  bottle  with  the  legend 
of  the  case  and  the  signature  of  the  physician.  It  is  well,  also,  to  give 
the  date  and  hour  of  the  examination. 

EXAMINATION  OF  VOMITUS. 

This  examination  is  seldom  of  importance  except  for  the  purpose 
of  determining  whether,  in  a  case  of  suspected  stricture  of  the  esophagus, 
the  food  ingested  reaches  the  stomach.  The  presence  of  HCl,  pepsin, 
and  rennet  is  generally  sufficient  evidence  that  the  vomitus  has  come  from 
the  stomach,  and  that  it  has  not  simply  been  regurgitated  from  the 
esophagus.  In  achylia  gastrica,  however,  these  substances  may  be  absent. 
The  coloring  matter  of  bile  should  be  tested  for,  and,  if  this  be  present, 
it  is  conclusive  evidence  that  the  food  has  come  from  the  stomach. 

Test  of  the  Motor  Power  of  the  Stomach.— If  food  is  brought  up  with 
the  water  in  lavage  of  the  stomach  seven  hours  or  longer  after  its  in- 
gestion, the  motor  power  of  the  stomach  is  deficient;  if  food  be  absent 
when  the  washing  is  done  within  three  or  five  hours  after  a  meal  of  mixed 
food,  it  is  evidence  of  increased  motility. 

Salol  Test. — A  gram  (gr.  xv)  of  salol  is  administered  in  capsules  im- 
mediately after  a  meal.  As  soon  as  this  substance  reaches  the  alka- 
line juice  of  the  intestine  it  is  converted  into  phenol  and  salicylic  acid, 
and  the  latter  substance  appears  almost  immediately  in  the  urine.  Its 
presence  is  detected  by  the  addition  to  the  urine  of  a  few  drops  of  a 
dilute  aqueous  solution  of  ferric  chlorid.  A  violet  or  brown  color  is 
significant  of  salicylic  acid.  The  test  should  be  repeated  every  half-hour 
until  a  reaction  is  obtained.  This  occurs  normally  in  an  hour  to  an 
hour  and  a  half.  Should  the  stomach-contents  be  alkaline,  however, 
the  reaction  appears  much  earlier  and  the  test  is  of  no  value. 

Test  of  Absorptive  Power.— From  0.20  to  0.40  gram  (gr.  iij— vj)  of 
potassium  iodid  should  be  administered,  during  fasting,  in  a  capsule 
freed  from  the  drug  upon  its  exterior.  The  saliva  is  then  tested  for  iodin 
with  starch-paper  at  intervals  of  one  or  two  minutes.  Normally  the  re- 
action is  obtained  in  five  to  fifteen  minutes.  A  much  longer  interval 
indicates  delayed  absorption. 

EXAMINATION  OF  INTESTINAL  DISCHARGES. 

The  feces  and  other  intestinal  discharges  may  be  submitted  to  macro- 
scopic, microscopic,  chemical,  and  bacteriological  examination. 


EXAMINATION  OF  INTESTINAL  DISCHARGES 


725 


Macroscopic  Examination.— Simple  inspection  of  the  feces  reveals 
their  color,  consistence,  and  form,  and  aftords  an  adequate  idea  of  the 
completeness  of  the  processes  of  digestion  as  well  as  of  the  presence  of 
parasites,  foreign  bodies,  blood,  pus,  fat,  shreds  of  tissue,  and  other 
abnormal  substances.  The  source  of  blood  may  be  inferred  from  its 
color  and  other  conditions.  WTien  the  fecal  mass  is  merely  streaked  with 
it,  the  source  of  the  hemorrhage  is  usually  at  or  near  the  anal  orifice ; 
when  bright  fluid  blood  accompanies  the  dejection,  it  is  generally  from 
the  rectum  and  may  be  due  to  hemorrhoids  or  ulcer.  When  the  blood 
is  coagulated  or  black  and  tarry,  its  source  is  higher  up  in  the  intestine 
or  stomach.  The  odor  also  reveals  to  some  extent  the  completeness 
of  the  digestion.  Segments  of  tapeworm  should  be  compressed  between 
two  slips  of  glass  in  order  to  render  them  more  translucent. 

Microscopic  Examination. — A  small  portion  should  be  picked  up  on 
the  platinum  loop,  transferred  to  a  slide,  and  mixed  with  a  drop  of  water, 
after  which  the  cover-glass  is  applied.  The  examination  should  be  made 
first  with  a  low  power.  The  substances  commonly  revealed  are  frag- 
ments   of  incompletely    digested   animal  or  vegetable  food,   as  muscle 


^  b  c  d 

Fig.  31. — Ova  of  intestinal  worms  (X275).  a,  Tenia  saggplnata  with  and  without 
albuminous  covering;  6,  ascaris  lumbricoides;  c,  trichocephalus  dispar;  c/,  anchylos- 
toma  duodenale.     (Nichols.) 


fibers,  connective-tissue  fibers,  starch-granules,  chlorophyll,  fat,  fatty-acid 
crystals,  cholesterin,  amorphous  and  granular  matter,  ammoniomag- 
nesium-phosphate  crystals,  calcium  oxalate  and  carbonate,  spermin  and 
hematoidin  crystals,  erythrocytes,  leucocytes,  epithelium,  saccharomyces 
and  other  fungi,  bacteria,  small  animal  parasites,  and  crystals  or  other 
remains  of  drugs  that  have  been  ingested. 

In  examining  for  small  parasites  and  ova,  a  moderate  quantity  of 
fecal  matter  should  be  placed  in  a  cylindrical  glass,  thoroughly  mixed 
with  water  and  allowed  to  stand  for  ten  minutes.  The  parasites  and 
ova  settle  to  the  bottom,  and  by  pouring  off  the  supernatant  fluid 
and  repeating  the  process  several  times  they  may  be  obtained  free 
from  extraneous  matter.  They  can  then  be  subjected  to  microscopic 
examination.  The  more  frequent  varieties  of  ova  are  illustrated  in 
Fig.  31. 

Fat-globules  can  be  more  distinctly  brought  out  by  staining  them  red 
with  Sudan  III.  To  prepare  this  solution,  first  allow  a  saturated  alco- 
holic solution  of  the  Sudan  III  to  stand  a  few  days,  then  add  one  part 


726  PRACTICE  OF  MEDICINE 

of  it  to  one  part  each  of  alcohol  and  water.    The  solution  is  ready  for 
use  as  soon  as  it  has  become  clear. 

Starch-cells  are  rendered  more  visible  by  treatment  with  dilute  Lugol's 
solution.  A  drop  of  acetic  acid  renders  leucocytes  and  epithelial  cells 
more  distinct,  and  dissolves  phosphates  and  carbonates,  the  latter  bodies 
evolving  minute  bubbles  of  carbonic  acid. 

Filn-in  may  be  stained  red  with  Ehrlich's  triple  stain  or  blue  with 
Weigert's  gentian-violet  stain.  Mucin  is  always  present,  and  when  ab- 
normally abundant  it  can  generally  be  recognized  without  the  micro- 
scope. If  its  identity  is  doubtful,  it  may  be  dried,  fixed  on  a  slide  with 
alcohol  or  mercuric-chlorid  solution,  and  stained  blue  with  methylene 
blue,  green  with  the  triple  stain,  and  reddish  with  toluidin  blue.  Solid 
tissue-particles  should  be  broken  up,  teased,  or  sectioned,  as  their  char- 
acter permits. 

Chemical  examination  is  seldom  of  sufficient  importance  to  justify 
the  labor.  The  reaction  is  often  of  importance,  however,  and  this  is 
determined  with  litmus-paper.  If  the  fecal  mass  be  firm  and  dry,  it 
must  be  broken  open,  and  the  moistened  litmus-paper  pressed  between 
its  surfaces.  A  quantitative  test  of  the  degree  of  acidity  or  alkalinity 
can  be  made  by  testing  a  watery  extract  of  a  definite  quantity  of  the  fe- 
cal matter,  using  the  titration  method  employed  for  stomach-contents. 

The  proteids  may  be  recognized  by  digesting  feces  with  water  acidu- 
lated with  acetic  acid,  and,  after  filtering,  applying  the  usual  tests  for 
albumin,  albumose,  and  pepton. 

For  the  carbohydrates  boil  a  small  quantity  of  the  matter  in  water, 
filter,  concentrate  the  filtrate  by  evaporation,  and  test  for  starch  and 
erythrodextrin  with  iodin,  and  for  sugar  with  the  urine  tests. 

Fat  and  Xk\^  fatty  acids  may  be  recognized  with  the  microscope  or 
by  extracting  with  ether  and  applying  the  tests  given  in  the  examination 
of  the  gastric  fluid. 

Bilirubin  may  be  detected  with  the  nitric-acid  test  applied  to  the 
aqueous  or  chloroform  extract,  or  the  acid  may  be  applied  directly  to 
the  fecal  mass.     The  green  color  is  distinctive. 

Blood  is  distinguished  by  the  hemin  test  applied  either  to  a  dried 
fragment  of  the  clot  or  to  an  evaporated  aqueous  extract  of  the  fecal 
matter.  The  guaiacum  test  may  also  be  applied  to  the  aqueous  ex- 
tract. 

Calculi. — For  the  discovery  of  these,  the  feces  should  be  mixed  with 
water  and  forced  through  a  sieve  of  fine  mesh.  The  sandlike  particles, 
if  too  small  for  macroscopic  recognition,  may  be  examined  chemically 
and  microscopically. 

Bacteriological  Examination.— The  micro-organisms  ordinarily  found 
in  the  intestinal  discharges  are  so  numerous  that  little  can  generally  be 
gained  from  an  attempt  to  isolate  them.  Many  of  them  can  generally 
be  recognized,  however,  with  any  of  the  usual  stains  applied  to  a  dried 
and  fixed  specimen  on  the  slide.     A  it^  are  worthy  of  note. 

The  Ameba  Coli. — The  feces  must  be  fresh  and  examined  before  cool- 
ing, on  a  warm  slide,  in  order  to  retain  the  ameboid  movement.  Tuber- 
cle bacilli  may  be  stained  in  the  usual  manner  after  drying  and  fixing 
on  a  slide.  Typhoid  bacilli  can  sometimes  be  obtained.  The  cholera 
vibrios  axe  usually  so  numerous  as  to  be  recognized  without  difficulty. 


EXAMINATION  OF  THE  URINE  727 

Plate-cultures  may  be  made  from  the  dejections,  but  the  growth  is 
generally  so  luxuriant  as  to  render  the  isolation  of  species  next  to  im- 
possible in  clinical  work. 

DISINFECTION  OF  DEJECTA. 

The  best  disinfecting  agents  for  this  purpose  are  a  1  :5oo  acidulated 
solution  of  mercuric  chlorid,  a  i  :2o  solution  of  carbolic  acid,  a  i  :2o 
solution  of  formalin,  and  chlorinated  lime.  The  latter  substance  should 
be  used  in  the  dry  state.  It  is  especially  suited  to  the  disinfection  of 
trenches  and  privies.  The  carbolic-acid  and  formalin  solutions  are  less 
corrosive  to  metallic  drain-pipes  than  the  corrosive  sublimate. 

The  disinfection  of  stools,  especially  in  typhoid  fever,  should  be  be- 
gun as  soon  as  the  disease  is  recognized,  and  continued  for  at  least  ten 
days  after  the  fever  has  subsided.  The  following  rules  should  be  ob- 
served : 

1.  The  bedpan  should  contain  a  pint  of  the  bichlorid  solution  at  all 
times,  ready  to  receive  the  dejection.  The  pan  must  be  cleansed  with 
boiling  water  and  one  of  the  disinfecting  solutions. 

2.  Enough  of  the  solution  should  be  poured  over  the  stool  to  cover 
it  and  be  thoroughly  mixed  with  it;  the  vessel  should  then  stand  two 
hours  before  it  is  emptied. 

3.  Lumps  of  fecal  matter  should  be  immediately  broken  up  with  a 
stick,  and  the  stick  subsequently  burned. 

4.  The  urine  should  be  disinfected  by  the  addition  of  enough  carbolic 
acid  or  mercuric  chlorid  to  convert  it  into  a  1:20  ori:5oo  solution, 
respectively. 

5.  All  linen  and  bedclothing should  be  soaked  in  a  i  :2o  carbolic-acid 
solution,  and  afterward  boiled  for  two  hours. 

6.  As  a  further  precaution,  the  nurses,  physicians,  and  other  attend- 
ants should  wash  their  hands,  and  immerse  them  in  a  i  :iooo  mercuric- 
chlorid  solution  after  handling  the  patient,  the  bedpan,  syringe,  ther- 
mometer, or  other  articles  coming  in  contact  with  him. 

EXAMINATION  OF  THE  URINE. 

The  Specimen. — To  secure  accurate  results  the  specimen  should  be 
taken  from  a  mixture  of  all  the  urine  voided  in  twenty-four  hours.  When 
this  cannot  be  done,  a  specimen  passed  three  hours  after  a  meal  is 
most  likely  to  reveal  any  abnormalities  present.  To  preserve  the  speci- 
men, a  few  drops  of  formalin,  chloroform,  or  alcohol,  or  a  few  grains 
of  chloral  or  salicylic  acid  may  be  added.  The  average  normal  quan- 
tity in  twenty-four  hours  is  from  1,200  to  1,500  c.c.  (40  to  50  ounces). 
The  reaction  of  a  mixed  specimen  is  usually  acid,  but  after  a  meal  con- 
sisting largely  of  carbohydrates  it  may  be  alkaline,  in  health. 

Reaction. — This  is  tested  with  litmus-paper.  Acid  urine  turns  blue 
litmus  red;  alkaline  urine  turns  red  litmus  blue.  An  amphoteric  reaction 
may  occur  in  which  both  papers  are  changed  by  the  same  specimen. 
Huppert  attributes  this  to  the  presence  of  acid  and  neutral  phosphates. 
When  the  blue  color  of  red  litmus  fades  upon  becoming  dry,  the  reaction 
is  due  to  a  volatile  alkali. 


728  PRACTICE  OF  MEDICINE 

Specific  Gravity. — This  can  be  determined  with  sufficient  accuracy  with 
the  ordinary  urinoraeter.  An  instrument  of  certified  accuracy  should  be  em- 
ployed, however,  as  many  of  those  offered  in  the  market  are  unrehable.  If 
the  specimen  be  fresh,  its  temperature  should  be  measured,  and  one  degree 
added  to  the  reading  of  the  urinometer  for  every  seven  degrees  of  tem- 
perature above  the  standard  of  the  instrument,  which  is  usually  60°  F. 

Solid  Ingredients.— The  simplest  method  of  approximately  estimating 
the  solids  of  the  urine  is  to  multiply  the  last  two  figures  of  the  specific 
gravity  by  2.33,  which  gives  the  number  of  grams  in  each  1,000  c.c. 

TESTS  FOR  N0R:^LA.L  INGREDIENTS. 

Urea. — Test. — To  a  drop  of  the  fluid  (urine)  on  a  slide  add  a  drop  of 
pure  nitric  acid  and  gently  warm.      Rhombic  or  hexagonal  prisms  or 
plates  of  urea  nitrate  are  formed,  and  are  visible  with  a  low 
Jlilli,      power. 

1    §  Biuret  Reaction.— To  the  urine  evaporated  almost  to  dry- 

^jlf%s,  £j      ness,  and  while  warm,   add  a  trace  of  potassium  hydroxid 
and  a  drop  of  dilute  cupric-sulphate  solution.    A  rose-red  or 
P  5  I     ^  ,       violet  color  denotes  urea. 

I  i-'||fi  E  Quantitative  Determination. — The  hypobromite   method   is 

''     '         generally  employed   by    means    of  the    Doremus    ureometer 
(Fig.  32). 

Two  solutions  are  required:    ((?)  Sodium  hydroxid  100, 
distilled  water  250;   and  (/^  bromin. 
'ij   l|  Immediately  before  the  test  is  made,    mix   i   c.c.   bromin 

I' I    11       with  10  c.c.  of  the  sodium-hydroxid  solution,  and  add  enough 
'  water  to  fill  the  long  arm  of  the  ureometer.    The  fluids  may 

be  mixed  in  the  ureometer.     The  instrument  is  reclined  so 
as  to  allow  the  fluids  to  fill  the  long  arm,  then  restored  to 
-x      the   upright  position.    One  cubic  centimeter  of  the 
urine  is  now  slowly  injected  from  a  pipette  into  the 
bulb  so  as  to  come  into  contact  with  the  hypobro- 
mite mixture  only  at  the  base  of  the  long  arm,   al- 
lowing the  liberated  nitrogen  to  collect  at  the  top. 
The    result  in  fractions  of  a  gram  of  urea  to    the 
Fig ~^— Doremus   cubic    centimeter    of  urine    may    be   read   from  the 
apparatus  for  the  es-   Scale  after  about  fifteen  minutes.    The    mark    0.02 
timation  of  urea.  represents  the  norm.al  2  per  cent. 

Uric  Acid. — Murexid  Test. — To  a  small  quantity 
of  the  sediment  or  to  the  residue  after  evaporation,  in  a  porcelain  cap- 
sule, add  a  few  drops  of  nitric  acid,  evaporate  over  a  flame  to  almost 
dryness,  and  add  a  drop  of  ammonia.  In  the  presence  of  uric  acid,  a 
beautiful  purple-red  color  is  produced. 

Silver  Tfst. — Moisten  a  piece  of  white  filter-paper  with  a  little  silver- 
nitrate  solution.  Touch  the  spot  with  a  drop  of  urine  made  alkaline 
with  sodium-carbonate  solution.  A  brownish  yellow  color  indicates  a 
trace,  and  black  o.ooi  per  cent  or  more  of  uric  acid. 

Xanthin. — With  a  few  drops  of  urine  mix  an  equal  quantity  of  nitric 
acid,  and  evaporate  to  dryness.  The  yellow  residue  is  changed  to  red 
by  potassium  hydroxid,  and  reddish  purple  by  heat. 


EXAMINATION  OF  THE  URINE  729 

Creat/'nin.  —  Weyl's  Test. — Add  to  the  urine,  solution  of  sodium  nitro- 
cyanid,  followed  by  sodium  hydroxid.  A  red  color  is  produced,  which 
turns  to  yellow  upon  standing. 

By  the  addition  of  zinc-chlorid  solution,  and  evaporation,  groups 
of  characteristic    crystals    of  creatinin-zinc    chlorid   are    formed    (Fig. 

Ferments. — Pepsin  has  been  found  in  normal  urine,  particularly  in 
that  voided  in  the  morning.  It  is  detected  by  soaking  small  pieces  of 
fibrin  in  the  urine,  then  removing  them  to  a  o.i  per  cent  solution  of 
hydrochloric  acid  at  37°  C,  where  they  are  quickly  digested.  Traces 
of  a  milk -curdling  ferment  like  rennet  and  a  diastatic  ferment,  probably 
trypsin,  have  been  isolated  from  the  urine. 

C hi 0 rids. — Add  to  the  urine  in  a  large  test-tube  a  little  nitric  acid 
to  hold  the  phosphates  in  solution,  then  a  drop  of  silver-nitrate  solu- 
tion (1:8).  A  precipitate  forms,  which  is  soluble  in  ammonia,  but  in- 
soluble in  nitric  acid.  If  the  precipitation  be  merely  a  flaky  white  cloud, 
the  chlorids  are  diminished  in  quantity;  if  it  be  a  heavy  white  mass, 
falling  quickly,  they  are  at  least  normal  in  quantity ;  if  there  be  no  pre- 
cipitate, they  are  absent. 

Quantitative  TQst.—Mohr's  Method.— Th.&  following  solutions  are  used  : 
(i)  A  standard  silver-nitrate  solution  made  by  dissolving  29.075  gm. 
of  pure  silver  nitrate  in  1,000  c.c.  of  distilled  water,   each  cubic  centi- 
meter of  which  will    precipitate    10     mgm.    (0.0 10) 
of  sodium  chlorid;   and    (2)    a    saturated    aqueous      ,^^**f*^^  ""% 
solution  of  neutral  potassium  chromate.  i.  * 

Dilute  10  c.c.   of  urine  with   100  c.c.  of  distilled    ^>"*    ''  .    m^^^fL^ 
water,  and  add  a  few  drops  of  the  potassium-chro-  ^^^ 

mate  solution.    Then  titrate  with  the  silver  solution.     „  /-      .•  • 

.         ,  .  .    .  r      ^^  1  1       ■  1     •  1  ,      rIG.    2)Z-  —  Creatinin- 

A  white  precipitate  01  silver  chlorid  is  produced  zjnc  chlorid  crystals. 
until  all  the  chlorids  have  been  removed;  then  a 
red  precipitate  of  silver  chromate  begins  to  form.  As  soon  as  the  pink 
color  becomes  permanent,  the  calculation  can  be  made  from  the  quan- 
tity of  silver  solution  that  has  been  used.  One  cubic  centimeter  should 
be  deducted  from  the  quantity  of  silver  solution,  however,  to  offset  the 
other  substances  which  unite  with  the  silver  before  the  potassium  chro- 
mate. 

Phosphates. — Earthy  Phosphates. — Render  the  urine  strongly  alkaline 
with  sodium,  potassium,  or  ammonia,  and  gently  warm.  The  earthy 
phosphates  are  precipitated  and  soon  settle.  If  in  a  test-tube  of  2  cm. 
diameter  they  form  a  deposit  to  the  depth  of  i  cm. ;  their  quantity  is 
normal. 

Alkaline  Phosphates. — Remove  the  precipitate  formed  in  the  preceding 
test.  To  the  filtrate  add  one-third  its  volume  of  a  solution  consisting  of 
magnesium  sulphate  and  ammonium  chlorid  each  i  part,  distilled  water 
8  parts,  and  pure  liquor  ammonia  i  part.  The  alkaUne  phosphates 
are  precipitated  in  a  white  cloud.  If  a  distinctly  creamy  appearance  is 
produced,  they  are  increased;  if  a  very  slight  opacity,  they  are  dimin- 
ished. 

Sulphates. — Acidulate  10  c.c.  of  urine  with  hydrochloric  acid,  and  add 
one-third  the  quantity  of  barium-chlorid  solution.  A  milky  white  pre- 
cipitate indicates  a  normal  quantity  of  the  sulphates. 


73Q  PRACTICE  OF  MEDICINE 

Carbonates. — The  addition  of  an  acid  to  urine  containing  carbonates 
liberates  carbonic  acid.  By  passing  this  gas  through  Hme-water  or 
baryta-water,  a  cloudy  precipitate  is  formed. 

ABNORMAL  CONSTITUENTS. 

Albumin. — Heat  the  upper  portion  of  a  column  of  urine  in  a  test-tube. 
A  precipitate  which  is  not  redissolved  by  the  addition  of  nitric  acid  is 
due  to  albumin.  Excess  of  acid  must  be  avoided.  Alkaline  urine  must 
be  rendered  acid  before  boiling.  This  test  reacts  to  globulin,  mucin, 
pine  acids  from  cubebs,  copaiba,  etc.,  and  albumose  is  precipitated  after 
the  specimen  becomes  cold.  The  pine-acid  precipitate  is  redissolved  by 
alcohol. 

Nitric  Acid  Test  (Heller). — Underflow  the  urine  with  nitric  acid  with- 
out mixing.  A  white  ring  is  formed  at  the  line  of  junction  corresponding 
in  depth  of  whiteness  with  the  quantity  of  albumin.  The  precipitate  may 
not  appear  for  an  hour  or  two.  Slightly  warming  the  urine  intensi- 
fies the  reaction  and  renders  nucleoalbumin  less  apt  to  appear.  A  cloudi- 
ness due  to  mucin  may  appear  at  a  little  distance  above  the  line  of 
contact. 

Purdy's  Heat  and  Acid  Test. — Add  to  the  urine  enough  of  a  filtered 
saturated  solution  of  sodium  chlorid  to  raise  its  specific  gravity  ten  or 
fifteen  degrees,  to  prevent  reaction  with  mucin.  To  two-thirds  of  a  test- 
tubeful  of  this  mixture  add  one  or  two  drops  of  strong  acetic  acid,  and 
boil  the  upper  inch  of  the  column  for  about  half  a  minute.  Albumin 
will  appear  in  the  boiled  portion  as  a  milky  turbidity.  This  is  one  of 
the  most  delicate  tests. 

Potassiiim-Ferrocyanid  Test. — Pour  into  a  clean  test-tube  15  to  30 
drops  of  acetic  acid,  add  to  it  three  or  four  times  as  much  of  a  5-per- 
cent solution  of  potassium  ferrocyanid,  and  shake.  Then  fill  the  tube 
two-thirds  full  of  the  urine.  Albumin  will  appear  as  a  more  or  less 
milky  cloudiness.  To  recognize  a  slight  cloudiness,  the  urine  tested 
should  be  compared  with  another  sample  of  the  same  urine  in  a  tube 
of  the  same  size.  This  is  one  of  the  most  reliable  tests,  as  it  reveals 
all  forms  of  albumin,  and  nothing  else.  It  must  be  performed  just  as 
directed. 

Potassium  Mercuric  lodid  Test. — The  following  solution  is  used :  Po- 
tassium iodid,  3.32  gm. ;  mercuric  chlorid,  1.35  gm. ;  acetic  acid,  20  c.c. ; 
distilled  water,  q.s.  to  make  100  c.c.  The  salts  are  dissolved  sepa- 
rately, the  solutions  mixed,  the  acetic  acid  added,  with  enough  water 
to  make  up  the  volume.  A  little  of  the  reagent  is  poured  into  a  test- 
tube,  and  the  urine  flowed  over  it  without  mixing.  The  test  is  sensitive 
to  albumin,  but  reacts  also  to  pepton,  proteoses,  mucin,  and  the  pine 
acids. 

Picric-Acid  Test. — Over  the  surface  of  the  urine  flow  a  saturated 
solution  of  picric  acid  (6  or  7  grains  dissolved  in  an  ounce  of  hot 
water).  Albumin  is  revealed  by  a  cloudiness  in  the  area  in  which  the 
fluids  mix.  Albumin,  mucin,  pepton,  proteoses,  and  vegetable  alkaloids 
respond  to  the  test,  but  all  except  albumin  and  mucin  are  redissolved 
by  heat. 

Biuret  Test. — Add  to  the  urine  a  solution  of  potassium  hydroxid,  then 


EXAMINATION  OF  THE  URINE  731 

a  weak  solution  of  cupric  sulphate,  drop  by  drop  from  a  pipette.  If 
albumin  be  present,  the  greenish  precipitate  is  redissolved  and  the  mix- 
ture assumes  a  reddish  violet  color.  Albumose  and  globulin  yield  the 
same  reaction,  urea  a  rose-red  or  violet,  and  pepton  a  red  color. 

Milloii's  Test. — Dissolve  one  part  of  mercury  in  two  parts  of  nitric 
acid  of  1.42  sp.  gr.,  and  dilute  with  two  volumes  of  water.  To  one 
dram  of  urine  add  ten  minims.  A  trace  of  albumin  is  recognized  by  a 
red  color  on  heating;  larger  quantities  produce  a  precipitate  which  be- 
comes red  on  heating.  The  test  reveals  the  aromatics  and  some  of  the 
benzol  group. 

Alcohol  Test  (Truax). — From  a  pipette  passed  down  nearly  to  the  sur- 
face of  98  per  cent  alcohol  in  a  test-tube,  drop  a  little  urine.  If  al- 
bumin be  present,  it  is  precipitated  in  a  whitish  streak  extending  to  the 
bottom  of  the  tube;  if  mucin  be  present,  a  general  cloudiness  is  pro- 
duced. 

Quantitative  Determination.— CV«/n/«^rt;/  Method.— lo  10  cc.  of  urine 
in  the  centrifuge  tube  add  3.5  cc.  10  per  cent  potassium-ferrocyanid 
solution,  and  1.5  cc.  acetic  acid,  and  mix  thoroughly.  After  revolving 
until  the  fluid  is  left  perfectly  clear,  each  tenth  cc  of  precipitate  at  the 
bottom  of  the  tube  denotes  i  per  cent  of  albumin  by  bulk.  It  should 
be  remembered  that  a  precipitate  amounting  to  50  per  cent  by  bulk  in 
any  of  the  tests  rarely  exceeds  2  per  cent  by  weight. 

Globulin. — Exactly  neutralize  the  urine,  and  filter;  then  add  magne- 
sium sulphate  until  it  no  longer  dissolves.  If  globulin  be  present,  a  white 
precipitate  is  formed. 

Roberts's  Test. — Globulin  falls  out  of  solution  when  the  specific  gravity 
is  reduced  below  1.002.  To  a  test-tubeful  of  distilled  water  add  the 
urine  by  drops.  If  globulin  be  present,  each  drop  is  followed  by  a  milky 
streak  until  the  entire  volume  becomes  opaque.  The  cloudiness  is  re- 
moved by  acetic  acid. 

Hemoglobin. —Heller's  Test. — Render  the  urine  strongly  alkaline  with 
sodium-hydroxid  solution,  and  heat  to  boiHng.  The  precipitate  of  earthy 
phosphates  is  colored  red  by  hematin.  If  the  urine  be  alkaline,  a  few 
drops  of  magnesium  solution  produces  an  artificial  precipitate,  which, 
when  heated,  brings  out  the  hematin.  The  guaiacum  and  hemin  tests 
may  also  be  employed. 

Fibrin. — The  urine  may  become  flaky,  coagulae  may  form,  or  it  may 
coagulate  into  a  firm  mass  after  being  voided,  especially  in  chyluria. 
The  fibrin  is  not  soluble  in  water,  swells  on  the  addition  of  hydro- 
chloric acid,  and  is  dissolved  by  pepsin  added  to  the  acid  fluid. 

Alkapton. — Test. — Add  to  the  urine  one  drop  of  a  very  dilute  ferric- 
chlorid  solution;  a  dull  green  color  is  produced,  which  immediately 
vanishes.  Repeated  additions  of  the  same  solution  produce  a  repetition 
of  the  reaction.  The  surface  of  alkapton  urine  becomes  dark  upon  ex- 
posure to  the  atmosphere,  and  the  discoloration  gradually  extends  to 
the  entire  specimen. 

TESTS   FOR   SUGAR. 

Trammer's  Test.— To  a  quantity  of  urine  in  a  test-tube  add  half  as 
much  sodium  or  potassium  hydroxid  solution  (i  13);  to  this  add  a  drop 
or  two  of  cupric-sulphate  solution   (1:10),   and  shake.     An  azure-blue 


732  PRACTICE  OF  MEDICINE 

color  i-s  produced.  Heat  the  mixture  to  boiling.  If  sugar  be  present, 
the  color  changes  first  to  yellow,  then  to  an  orange-red.  Although  the 
azure-blue  color  is  not  sufficiently  distinctive,  it  does  not  usually  appear 
in  the  absence  of  sugar. 

Fehling's  Test. — The  following  reagents  are  required :  («)  Copper 
solution:  Dissolve  of  pure  crystallized  cupric  sulphate,  34.64  gm.,  in 
enough  of  distilled  water  to  make  500  c.c.  (^)  Rochelle  salt  solution: 
Dissolve  sodium  hydroxid,  125  gm.,  and  chemically  pure  potassium- 
sodium  tartrate,  173  gm.,  in  sufficient  distilled  water  to  make  500  c.c. 
These  solutions  may  be  preserved  in  well-stoppered  bottles.  Fehling's 
solution  is  made  by  mixing  them  in  equal  parts  at  the  time  of  using. 

The  Method. — About  i  c.c.  of  the  FehHng  solution  is  diluted  in  a  test- 
tube  with  three  or  four  times  as  much  distilled  water,  and  boiled.  If  no 
change  of  color  is  produced,  the  urine  is  added  drop  by  drop  until  a 
slight  reduction  of  the  copper  occurs,  as  indicated  by  a  yellow  color, 
or  until  the  quantity  of  added  urine  equals  that  of  the  reagent.  The 
mixture  is  again  heated,  and  if  no  reduction  occurs  the  test  is  set  aside 
for  several  hours.  If  there  is  still  no  reaction,  sugar  is  absent.  The 
test  is  one  of  the  most  delicate.  If  the  reagent  change  color  in  the 
preliminary  boiling,  new  solutions  must  be  obtained. 

Haines's  Test. — Formula:   Copper  sulphate  30  grains,   distilled  water 


,<.MMlif,„/,., 


Fig.  34. — Rosette  and  rays  of  phenylglucosazone  crystals. 

a  half  ounce;  make  a  perfect  solution  and  add  glycerin  a  half  ounce; 
mix  thoroughly  and  add  liquor  potassae  5  ounces.  Boil  about  a  dram 
of  the  solution  in  a  test-tube,  add  not  more  than  6  or  8  drams  of  the 
urine,  and  boil  gently.  If  sugar  be  present,  a  copious  yellow  or  orange 
precipitate  is  thrown  down. 

Bottger's  Bisjnuth  Test. — Add  to  the  urine  in  a  test-tube  an  equal 
volume  of  sodium-hydroxid  solution  and  a  very  small  quantity  of  pure 
bismuth  subnitrate.  Boil  gently  for  one  or  two  minutes.  If  sugar  be 
present,  the  mixture  turns  gray,  brown,  or  black,  according  to  the  quan- 
tity of  sugar.  If  the  quantity  be  very  small,  only  the  bismuth  is  dis- 
colored. Albumin  and  other  sulphur  compounds  must  first  be  removed. 
The  test  must  not  be  made  in  a  test-tube  that  has  been  previously  used 
for  either  of  the  copper  tests. 

Fhenylhydrazin  Test. — To  25  c.c.  of  urine  in  a  capsule  add  i  gm. 
phenylhydrazin  hydrochlorid,  0.75  gm.  sodium  acetate,  and  10  c.c.  dis- 
tilled water.  Warm  the  mixture  for  an  hour  on  a  water-bath,  remove, 
and  let  cool.  If  sugar  be  present,  a  yellowish  deposit  is  formed,  which 
the  microscope  shows  to  be  composed  of  fine,  brilliant  yellow  crystals 
arranged  singly  or  in  stars   (Fig.   34).     This  phenylglucosazon  melts 


EXAMINATIOX  OF  THE  URINE  733 

at  204°  C.  Yellow  scales  or  spheres  do  not  denote  sugar.  Care  must 
be  taken  not  to  allow  the  phenylhydrazin  to  come  in  contact  with  the 
hands. 

Fermejitation  Test. — The  simplest  accurate  method  of  performing  this 
test  is  by  filling  a  test-tube  about  half  full  of  mercury,  and  completely 
filling  the  remainder  of  the  tube  with  the  urine,  introducing  a  small 
piece  of  compressed  yeast  and  inverting  the  tube  over  a  vessel  of  mer- 
cury. Then  set  the  tube  in  a  warm  place  for  several  hours.  If  fermen- 
tation occur,  the  carbonic-acid  gas  collects  in  the  upper  extremity  of 
the  tube.  A  special  apparatus  may  be  purchased,  or  it  may  be  easily 
made  by  passing  a  doubly  bent  tube  through  a  cork  nearly  to  the  bot- 
tom of  a  bottle  containing  the  urine  and  yeast,  hermetically  sealing  the 
cork.  If  sugar  be  present,  the  urine  is  expelled  through  the  tube,  its 
place  being  taken  by  the  carbonic-acid  gas.  A  control  test  should  be 
made  with  distilled  water  and  }^east  from  the  same  piece,  for  yeast 
sometimes  undergoes  spontaneous  fermentation,  probably  due  to  the 
presence  of  sugar  in  it.  A  second  control  may  be  made  with  a  weak 
solution  of  glucose,  in  order  to  prove  the  vitality  of  the  yeast. 

Heller-Moore  Test. — To  a  little  urine  in  a  test-tube  add  half  its  volume 
of  sodium-hydroxid  solution  and  heat  to  boiling;  if  the  precipitation 
of  earthy  phosphates  is  abundant,  filter.  As  the  mixture  becomes  hot, 
a  yellow,  yellowish  brown,  or  brownish  black  color  appears  if  sugar  be 
present.  Now  add  a  few  drops  of  nitric  acid.  The  color  vanishes  and 
an  odor  of  molasses  (caramel)  is  given  off.  Albumin  must  first  be  re- 
moved. Highly  colored  urine  should  be  decolorized  by  filtration  through 
animal  charcoal. 

Picric-Acid  Test. — To  a  small  quantity  of  urine  add  two-thirds  as  much 
saturated  solution  of  picric  acid,  and  the  same  quantity  of  liquor  potas- 
sae.  An  orange  color  results  from  the  incipient  reducing  action  of  creat- 
inin  on  the  picric  'acid.  Turbidity  denotes  albumin,  but  does  not  in- 
terfere with  the  test.  Boil  the  mixture  for  one  minute;  if  sugar  be 
present,  a  deep  mahogany-color  is  produced,  much  deeper  than  that 
which  occurs  in  normal  urine. 

Quantitative  Determination.— /'wr^/v'j-  Method.— T\it  formula  of  the 
standard  solution  is:  Cupric  sulphate,  C.P.,  4.742  gm. ;  potassium 
hydroxid,  C.P.,  23.50;  glycerin,  C.P.,  38  c.c. ;  strong  ammonia,  U.  S.  P. 
(sp.  gr.  0.9),  450  c.c;  distilled  water,  to  make  1,000  c.c.  Dissolve 
the  copper  and  glycerin  in  200  c.c.  of  distilled  water  with  the  aid  of 
gentle  heat.  In  another  200  c.c.  of  the  distilled  water  dissolve  the 
potassium  hydroxid.  Mix  the  two  solutions,  and  when  cold  add  the 
ammonia  with  enough  distilled  water  to  bring  the  whole  volume  up  to 
1,000  c.c. 

Place  exactly  35  c.c.  of  this  test  solution  in  the  flask,  dilute  it  with 
two  volumes  of  distilled  water,  and  bring  the  whole  thoroughly  to  the 
boiling-point.  Fill  the  burette  to  the  zero  mark  with  the  urine  to  be 
tested,  and  slowly  discharge  it  into  the  test-solution,  drop  by  drop, 
until  the  blue  color  begins  to  fade,  then  more  slowly  until  the  color 
permanently  disappears  and  leaves  the  fluid  perfectly  clear  and  trans- 
lucent. The  blue  color  may  return  after  some  time,  but  it  is  due  only 
to  the  absorption  of  oxygen.  The  percentage  of  sugar  is  thus  calcu- 
lated :    If  the  35  c.c.   of  solution  were   reduced  by  2  c.c.  of  urine,  the 


734  PRACTICE  OF  MEDICINE 

latter  contained  i  per  cent  of  sugar;   if  by  i  c.c,  2  per  cent  of  sugar; 
if  by  0.75  c.c,  3  per  cent;  if  by  0.5  c.c,  4  per  cent,  etc 

Bile  Acids. — Pettenkofer' s  Test. — Concentrated  sulphuric  acid  free  from 
nitric  or  sulphurous  acid  is  very  slowly  added  in  nearly  equal  volume 
to  the  urine,  the  test-glass  being  held  in  ice-water  to  prevent  rise  of 
temperature  above  60°  C.  A  10  per  cent  solution  of  cane-sugar  is  then 
added  drop  by  drop,  with  constant  stirring.  A  beautiful  red  color  in- 
dicates the  presence  of  bile  acids.  The  color  becomes  a  bluish  violet 
in  the  course  of  a  few  days. 

Bile  Pigmeni. — Gmelin's  Test. — Place  in  a  test-tube  a  little  strong  nitric 
acid  containing  some  commercial  yellow  nitrous  acid,  and  flow  over  it 
the  urine  to  be  tested.  A  layer  of  green  will  form  at  the  line  of  con- 
tact, surmounted  from  below  upward  by  layers  of  blue,  violet,  red,  and 
yellow,  the  green  being  distinctive  of  the  bile  pigment. 

Rosenbach  modifies  the  foregoing  test  by  passing  the  urine  through 
a  fine,  thick  filter,  then  applying  a  drop  of  the  nitrous-nitric  acid  to  the 
filter.  A  pale  yellow  spot  is  formed,  surrounded  by  rings  of  yellowish 
red,  violet,  blue,  and  green. 

Hener''s  Test. — About  a  dram  of  pure  hydrochloric  acid  is  placed  in 
a  test-tube,  and  just  enough  urine  mixed  with  it  to  distinctly  color 
it.  The  mixture  is  then  flowed  upon  a  column  of  nitric  acid,  and  a 
beautiful  play  of  colors  is  produced.  If  the  nitric  acid  be  now  stirred 
with  a  glass  rod,  the  colors  are  distributed  in  layers  throughout  the 
mixture. 

Ultzmann^s  Test. — Ten  c.c  of  urine  are  treated  with  3  or  4  c.c.  of  a 
strong  potassium-hydroxid  solution  and  acidified  with  hydrochloric 
acid.     If  bile  pigment  be  present,  a  beautiful  green  color  is  produced. 

Indican  (Indoxyl-Sulphuric  Acid). — Heller^ s  Test. — To  a  dram  of  HCl 
in  a  small  wine-glass  add  slowly,  with  constant  stirring,  about  20  drops 
of  urine.  If  the  color  produced  be  a  pale  yellow,  th^  indican  is  normal 
in  quantity ;  if  blue  or  violet,  it  is  increased.  The  addition  of  a  drop 
or  two  of  nitric  acid  renders  the  test  more  delicate. 

McMimn's  Test. — Equal  parts  of  urine  and  HCl  with  a  few  drops  of 
nitric  acid  are  boiled  together,  cooled,  and  agitated  with  chloroform. 
If  much  indican  be  present,  the  chloroform  takes  a  violet  color. 

Diazo  Reaction. — Two  solutions  are  required:  (i)  Sulphanilic  acid 
2  gm.,  and  hydrochloric  acid  50  c.c,  in  1,000  c.c.  of  distilled  water; 
(2)  a  0.5  per  cent  solution  of  sodium  nitrate. 

Mix  one  part  of  No.  2  with  50  parts  of  No.  i,  add  to  the  mixture 
an  equal  volume  of  the  urine,  render  strongly  alkaline  with  ammonia, 
and  shake  well.  The  characteristic  reaction  consists  in  the  production 
of  a  carmine  color  both  in  the  mixture  and  in  the  foam.  Normal  urine 
yields  a  yellow  color.  The  test  may  be  performed  by  the  contact  method, 
by  carefully  flowing  the  ammonia  upon  the  surface  without  mixing.  A 
brownish-red  ring  is  formed  at  the  junction  of  the  fluids. 

DRUGS  IN  THE.  URINE. 

Arsenic— Reinsch's  Test.—kA^  to  the  urine  in  a  test-tube  a  few  drops 
of  hydrochloric  acid,  then  introduce  a  piece  of  pure,  bright  copper  foil 
y^,  inch  square,  and  boil  for  several  minutes.     If  arsenic  be  present,  a 


EXAMINATION  OF  THE  URINE.  735 

dark  gray  coating  is  deposited  on  the  copper.  The  test  is  more  delicate 
if  the  urine  be  concentrated  by  slow  evaporation. 

Lead. —  Wood's  Test. — For  four  or  five  days  before  securing  the  speci- 
men, the  patient  takes  5  to  10  grains  of  potassium  iodid  three  times  a 
day.  A  liter  of  urine  is  then  obtained,  evaporated  to  dryness,  and  fused 
in  a  crucible  with  a  little  pure  potassium  nitrate  until  it  becomes  white. 
When  cool,  the  residue  is  extracted  with  hot  dilute  hydrochloric  acid, 
filtered,  the  filtrate  rendered  alkaline  with  ammonia  to  precipitate  the 
phosphates  and  iron.  Ammonium  sulphid  is  now  added  to  precipitate 
the  lead,  the  precipitate  is  washed  three  times  with  hot  distilled  water 
and  decanted,  water  acidified  with  hydrochloric  acid  is  added,  and  the 
whole  is  allowed  to  stand  until  the  next  day.  It  is  then  filtered  through 
a  small  filter,  the  precipitate  is  washed,  and  a  little  nitric  acid  is  added 
drop  by  drop  to  dissolve  the  lead  and  carry  it  through  as  a  nitrate. 
The  filtrate  is  collected  in  a  watch-glass  and  evaporated  to  dryness, 
and  the  final  test  is  made  by  adding  a  drop  of  water  and  a  crystal  of 
potassium  iodid.  The  formation  of  a  yellow  precipitate  denotes  the 
presence  of  lead. 

Mercury. — To  a  liter  of  urine  add  10  c.c.  of  hydrochloric  acid,  intro- 
duce a  little  piece  of  copper  foil,  and  apply  heat.  After  letting  the  urine 
stand  for  twenty -four  hours,  remove  the  copper  foil,  wash  it  with  water, 
alcohol,  and  ether,  and  let  it  dry.  Then  introduce  it  into  a  long  test- 
tube  and  heat  it  to  redness.  If  mercury  be  present,  it  condenses  on  the 
cool  part  of  the  tube.  If  fumes  of  iodin  be  now  introduced,  the  mer- 
cury is  changed  into  mercuric  iodid,  having  a  red  color. 

Bromin  and  Iodin. — Add  to  the  urine  a  little  fuming  nitric  acid  or 
some  freshly  prepared  chlorin-water,  and  shake  with  chloroform.  If 
bromin  be  present,  the  chloroform  assumes  a  brownish  yellow  color. 
If  iodin  be  present,  a  carmine  or  purple  color  is  produced.  If  the  urine 
be  ammoniacal,  potassium-hydroxid  solution  should  be  added  to  the 
urine  before  making  the  test  (Gillett). 

Quinin. — To  about  10  c.c.  of  urine  in  a  test-tube  add  a  drop  or  two 
of  HCl,  then  2  drops  of  chlorin-water  and  an  excess  of  ammonia.  An 
emerald-green  color  is  produced,  which  corresponds  to  the  quantity  of 
quinin  present.  Carefully  neutralize  the  mixture,  and  the  color  turns 
to  blue;  add  an  excess  of  an  acid  and  it  becomes  purple  or  red;  again 
add  an  excess  of  ammonia,  and  the  green  color  is  restored. 

Acetanilid. — Evaporate  the  urine  to  about  half  its  volume,  add  HCl 
and  boil  for  a  few  minutes;  extract  with  ether,  evaporate  the  ether, 
treat  the  residue  with  distilled  water,  add  a  few  c.c.  of  an  aqueous 
solution  of  phenol  and  half  as  much  of  a  i  per  cent  solution  of  calcium 
hypochlorite.  A  pale  green  (onion-peel)  color  is  produced,  which  changes 
to  blue  on  the  addition  of  ammonia.  If  the  urine  is  pale,  the  extraction 
with  ether  may  be  omitted. 

Antipyrin. — The  addition  of  ferric  chlorid  to  urine  containing  anti- 
pyrin  produces  a  red  color. 

If  antipyrin  be  also  present  in  the  test  for  quinin,  the  urine  acquires 
a  red  color  on  the  first  addition  of  ammonia. 

Morphin. — Add  to  the  urine  a  little  chloroform  containing  one  or  two 
drops  of  iodic  acid.  As  the  chloroform  sinks  to  the  bottom,  it  takes  up 
iodin  and  acquires  a  pink  color  corresponding  in  depth  to  the  quantity 


736 


PRACTICE  OF  MEDICINE 


of  morphin  present.  Now  render  the  mixture  alkaline  with  ammonia; 
the  pink  color  is  discharged  from  the  chloroform,  and  the  supernatant 
fluid  becomes  deep  brown. 

Salicylic  Acid. — To  lo  c.c.  of  urine  add  i  c.c.  of  strong  ferric-chlorid  solu- 
tion. Salicylic  acid  (salicyluric  acid)  produces  a  violet  color.  Diabetic 
urine  may  give  the  same  reaction  without  the  presence  of  this  substance. 

Santonin. — The  bright  yellow  urine  becomes  red  on  the  addition  of 
an  alkali,  and  the  color  gradually  fades. 

Rhubarb  and  senna  give  the  same  color-change  on  the  addition  of  an 
alkali  to  the  urine,  but  the  color  is  permanent.  Add  baryta-water  to  the 
fluid,  and  filter ;  if  the  color  pass  through  with  the  filtrate,  it  is  due  to 
santonin ;  if  it  remain  with  the  precipitate,  it  is  due  to  rhubarb  or  senna. 

Pine  Acids. — The  acids  and  salts  of  pine  appear  in  the  urine  after 
the  ingestion  of  balsams,  cubebs,  and  sometimes  after  turpentine  has 
been  taken.  The  addition  of  strong  nitric  or  hydrochloric  acid  pro- 
duces a  precipitate  like  that  of  albumin,  but  it  is  dissolved  by  strong 
alcohol.    Urine  containing  turpentine  often  has  the  odor  of  violets. 


URINARY  SEDIMENTS. 

To  obtain  the  sediment  from  a  specimen,  the  fluid  should  stand  about 
seven  hours  in  a  conical  glass.    The  supernatant  portion  may  then  be 

decanted  slowly;  the  last  cubic  centimeter  will 
usually  contain  a  representative  quantity  of 
the  sediment.  A  much  quicker  and  better 
method  is  by  means  of  the  centrifuge,  since 
time  is  not  thus  allowed  for  the  destruction  of 
the  anatomical  elements  by  bacteria. 

Chemical  Sediments.- —  Uric-acid  crystals  are 
found  almost  exclusively  in  acid  urine,  and 
they  constitute  the  only  ingredients  of  acid 
urine  which  have  a  yellow  color.  They  fre- 
quently crystallize  upon  the  side  of  the  vessel 
They  are  for  the  most  part  rhomboidal,  but 
may  be  rectangular,  or  having  rounded  ends  may  appear  ovoidal  or 
circular.  They  are  usually  flattened,  but  may  be  cubical  and  often  form 
stars  or  clusters  (Fig.  35). 

Urates. — The  urates  of  sodium  and  potassium  may  be  found  in  acid 
urine,  rarely  also  that  of  calcium.    Ammonium  urate  is  nearly  always 


Fig.  35. — Uric-acid  crystals. 
A,  Crystallization  on  a  cot- 
ton fiber. 

or  upon  foreign  bodies. 


Fig.  2)^. — Crj'stals  of  ammonium  urate. 

found  in  alkaline  urine.    Sodium  urate  appears  as  an  amorphous,  "  brick- 
dust"  deposit,  and  is  very  insoluble,  sometimes  in  the  form  of  fan-shaped 


EXAMINATION  OF  THE  URINE 


737 


^ 


<> 


or  stellate  clusters  or    needles.     Potassium  acid-urate  appears  only  in 

amorphous  form,   more  soluble  than  the  sodium  salt.     Calcium  urate 

occurs  m  acid  urine  as  an  amorphous  white  or 

gray  deposit.     Ammonium  urate  occurs  in  the 

form  of  dark  brown  crystalline  spheres  studded 

with  fine  spiculae,  which  are  known  as  mulberry 

crystals  (Fig.  36). 

Calcium  Oxalate. — These  crystals  occur  in 
either  acid  or  alkaline  urine,  as  small,  highly 
refracting  octahedra,  "  envelope"  crystals,  or 
as  circular  or  ovoid  disks  with  central  depres- 
sions, "dumbbell"  crystals  (Fig.  37). 

Phosphates. — Only  the  alkaline  phosphates  are  found  in  urinary  sedi- 
ment. They  occur  as  triple  ammonium-magnesium  phosphates  or  as 
calcium  phosphates.    The  most  frequent  appearance  is  that  of  triangular 


Fig 

crystals. 


Ij. — Calcium-oxalate 


Fig.    Ty?s. — Cr\fstals    of    ammonium-magnesium    phosphate    (from    a    camera-iucida 
sketch).     The  cr_vstal  at  the  extreme  left  is  probably  calcium   phosphate. 


prisms  having  beveled  ends,  the  "coffin-lid"  crystals  (Fig.  38),  rarely 
that  of  rosettes  or  star-shaped  bunches  of  feathery  crystals  resembling 
fern  leaves.    They  are  found  only  in  alkaline  urine. 

Leucin  and  Tyrosin.—Leucm  occurs  in  yellowish,  highly  refracting 
spheres,  resembhng  fat-globules,  but  in  a  pure  state  it  crystallizes  in 

irregular  scales  or  rosettes  having  a  greasy 
feel.    The  spherules  are  insoluble  in  ether. 

Tyrosin  crystallizes  in  the  form  of  fine 
needles  arranged  in'  sheafy  bundles;  some- 
times, in  alkaline  urine,  in  the  form  of  ro- 
settes (Fig.  39).  It  is  readily  soluble  in  hot 
water,  acids  and  alkalis,  insoluble  in  alco- 
hol or  ether. 

Melanin. — The  urine  may  be  dark  colored 
when  voided,  or  becomes  so  after  exposure 
to  the  air,  or  upon  the  addition  of  sulphuric  or  hydrochloric  acid  or 
ferric  chlorid.  The  addition  of  bromin-water  produces  a  yellow  pre- 
cipitate which  turns  to  black.     (See  also  Alkapton  test,  p.  731.) 

The  microscope  reveals  small  granules  insoluble  in  cold  alcohol,  ether, 
acetic  acid,  or  dilute  mineral  acids,  but  soluble  in  strong  solutions  of 
ammonium,  sodium,  or  potassium  hydroxid,  and  in  boiling  acetic,  lactic, 
and  mineral  acids. 

Fat  appears  in  the  urine  as  small,  highly  refracting  granules  with 
dark  margins,  which  are  soluble  in  ether,  chloroform,  benzol,  carbon 
disulphid,  and  hot  alcohol. 

47 


Fig.  39. — Leucin  spherules  and 
tyrosin  crystals. 


738 


PRACTICE  OF  MEDICINE 


ANATOMICAL  SEDIMENTS. 

Epiihelium  is  almost  invariably  found  in  the  sediment,  whether  the 
urine  be  normal  or  pathological.  Each  division  of  the  urinary  tract 
has  its  typical  surface  epithelium,  but  of  no  cell  can  it  be  said  that  it 

a  be 


o 


©  @@o^@ 


Fig.  41.— Blood  cells   and 
blood-casts. 


Fig.  40. — Types  of  epithelium  found  in  the  sediment  of  urine,  a,  From  the  kidney 
and  ureter;   b,  from  the  bladder;   c,  from  the  vagina. 

originates  in  one  division  alone,  especially  in  pathological  urine,  for  im- 
mature and  transitional  forms  from  the  deeper  layers  often  appear. 
The  three  principal  types  of  cells  are  shown  in  Fig.  40. 

Pus. — Purulent  urine  is  often  cloudy  or  milky.  Under  the  microscope 
pus-cells  appear  as  pale,  finely  granular  spherical  cells  about  the  size 
of  leucocytes,  containing  from  one  to  three  nuclei.     Water  and   acetic 

acid  cause  them  to  swell  and  become  more 
delicate  in  outline,  the  acid  at  the  same  time 
causing  the  granular  matter  to  disappear  and 
rendering  the  nuclei  more  distinct.  The  pus- 
cells  in  urine  are  dead  and  show  no  ameboid 
movement.  In  alkaline  urine  they  usually  fuse 
into  a  glairy  mass  at  the  bottom  of  the  speci- 
men, and  cannot  be  recognized  with  the  micro- 
scope. 

Blood. — When  abundant,  blood  gives  to  the 
urine  a  color  varying  with  its  quantity  from  a  dark  red  or  smoky 
hue  in  acid  urine  to  a  bright  red  in  alkaline  urine,  or  there  may  be  a 
reddish  brown  granular  sediment.  Coagula  may  be  found.  Albumin  is 
always  to  be  detected.  The  corpuscles  are  usually  scattered  singly  over 
the  field  of  the  microscope,  rarely  forming  rouleaux.  When  the  blood 
originates  in  the  kidney,  casts  are  usually  present   (Fig.   41).     Gum- 

Fig.  42.— Peculiar  forms  of  blood-corpuscles  found  in  hematuria  of  renal  origin, 
(After  Gumprecht.) 

precht  has  shown  that  in  renal  hematuria  the  red  cells  are  fewer  in 
number  than  in  that  of  vesical  origin ;  the  corpuscles  usually  undergo 
fragmentation  and  often  assume  peculiar  forms  (Fig.  42). 


URINARY  CASTS. 


The  urine  should  be  examined  as  fresh  as  possible,  and  for  this  rea- 
son centrifugal  precipitation  is  to  be  preferred.    It  is  better  to  place  a 


EXAMINATION  OF  THE  URINE 


739 


piece  of  hair  under  the  cover-glass  in  order  to  avoid  forcing  the  casts 
out  from  under  it.  A  moderately  low  power  should  first  be  used  in 
order  to  determine  the  presence  of  casts,  then  a  high  power  (^)  to 
determine  their  character.  The  light  should  not  be  too  strong.  Oblique 
illumination  is  often  better,  especially  for  the  hyalin-cast. 


Fig.  43.— Renal  casts,    a,  Hyalin;   b,  granular;  c,  epithelial. 

The  principal  forms  of  casts  are :  hyalin,  granular,  epithelial,  waxy, 
fatty,  and  blood  casts.  These  are  shown  in  Figs.  43  and  44.  Amor- 
phous urates  and  foreign  matter  sometimes  assume  the  form  of  false 
casts  (Fig.  44,  c). 

Spermatozoa  axe  little  threadlike  bodies  about  1-600  inch  in  length 
and  have  flattened,  oval  heads.    Under  favorable  conditions  of  heat  and 


Fig.   44.— Renal  casts,    a.  Waxy;  b,  fatty;  c,  amorphous  urate  and  other  false  casts. 

moisture  they  exhibit  a  vermicular  motion,  'but  are  usually  motionless 
when  found  in  the  urine. 

Fragments  of  tumors  are  sometimes  found  in  the  urine,  but  they  are 
seldom  of  sufficient  size  to  permit  of  proper  hardening  and  cutting.  A 
diagnosis  should  not,  as  a  rule,  be  based  upon  their  appearance  under 
the  microscope. 

ANIMAL   PARASITES. 

Distoma  Hematobium.— Theova  of  this  parasite  are  oval,  about  1-200 
inch  long,  with  a  sharp,  projecting  anterior  extremity  and  containing 
a  distinctly  visible  embryo.  They  are  usually  accompanied  with  blood, 
and  sometimes  with  fat. 

Filaria  Sanguinis  Hominis.— This  parasite  is  usually  found  in  chylous 
urine.  It  is  about  as  wide  as  a  red  blood-corpuscle  and  about  fifty 
times  as  long.  It  has  a  short,  rounded  head  and  a  long,  pointed  tail. 
The  body  is  granular  and  has  transverse  striations. 


740  PRACTICE  OF  MEDICINE 

Echinococcus. — The  booklets  and  scolices  of  the  echinococcus  rarely 
find  their  way  into  the  urine.  They  may  appear,  however,  entire  or  in 
fragments,  and  may  be  accompanied  bv  pieces  of  the  chitinous  mem- 
brane, usually  with  blood,  pus,   and  cellular  debris. 

Other  parasites  rarely  found  in  the  urine  are  the  trichomonas,  oxy- 
uris  vermicularis,  and  the  strongylus  gigas.  A  peculiar  ameba  and  an 
infusorium  have  also  been  described. 

VEGETABLE-PARASITES. 

Nearly  forty  varieties  of  bacteria  have  been  recognized  in  the  urine. 
These  belong  to  the  two  classes  of  pathogenic    and  nonpathogenic  or- 


cco 


Fig.  45.— Yeast  plant.  Fig.  46.— Sarcinse  of  Fig.  47.— The  micrococcus 

urine.  urese. 

ganisms.  Molds  seldom  form,  except  when  sugar  is  present.  The  yeast 
plant  (Fig.  45)  is  occasionally  found,  in  single  cells  or  in  chains.  Sar- 
cinae  (Fig.  46)  have  been  found  in  acid  urine.  They  are  sometimes 
larger  than  those  found  in  the  stomach.  The  micrococcus  ureae  is  a 
rather  large  micrococcus,  growing  in  chains  in  alkaline  urine.  All  these 
nonpathogenic  bacteria  are  found,  for  the  most  part,  in  connection  with 
retention  due  to  stricture,  cystitis,  enlarged  prostate,  paralysis,  etc. 

Pathogenic  Bacteria. — The  pathogenic  bacteria  may  be  described  under 
the  heads  of  micrococci  and  bacilli. 

The  micrococci  belong  chiefly  to  the  pus-formers  and  include  the 
streptococci  ureae,  pyogenes,  and  rugosus;  the  staphylococci  pyogenes 
albus,  aureus,  and  citreus;  several  diplococci  and  many  others.  The 
gonococcus  belongs  to  this  class. 

The  most  important  bacilli  are  the  coli  communis,  tuberculosis,  and 
typhosus. 

The  micrococci,  as  a  rule,  require  no  special  methods  of  staining,  all 
that  is  necessary  being  to  place  a  drop  of  the  sediment  on  a  slide,  add 


Fig.  49. — Tubercle  bacilli. 

a  drop  of  any  anilin  stain,  remove  the  excess  of  coloring  matter  after 
a  few  minutes,  and  examine  with  a  high  power. 

The  gonococcus  is  hemispherical,   and  so  arranged  in  pairs  that  the 
inner,  flat  or  slightly  concave  side  of  each  is  separated  from  that  of  its 


BACTERIOLOGICAL  METHODS  741 

fellow  by  a  narrow  interval  (Fig.  48).  They  are  sometimes  grouped  as 
tetrads,  and  are  generally  found  in  pus-cells  or  attached  to  epithehum. 
Anilin  blue  or  violet  is  the  best  stain. 

The  Bacillus  tuberculosis  (Fig.  49)  is  detected  in  the  urine  with  much 
difficulty,  as  a  rule,  owing  to  the  uncertainty  of  securing  the  specimen 
from  so  great  a  quantity  of  fluid,  and  still  greater  difficulty  of  fixing  it. 
The  method  of  staining  is  the  same  as  that  employed  in  examination 
of  sputum. 

Bacillus  Typhosus. — This  organism  may  be  stained  by  Ziehl's  method, 
acetic  acid  being  used  to  decolorize  instead  of  sulphuric  or  nitric  acid. 
Better  results  are  obtained  by  staining  for  twenty-four  hours  in  Lof- 
fler's  alkaline  methylene-blue  solution. 

The  Bacillus  coli  commutiis  is  differentiated  from  the  B.  typhosus  with 
much  difficulty,  and  chiefly  by  its  behavior  upon  different  culture-media, 
which  the  student  will  find  fully  described  in  his  textbook  on  bacteri- 
olog>^ 

CRYOSCOPY. 

The  apparatus  necessary  for  the  determination  of  the  freezing-point 
of  urine  consists  of  a  double  test-tube,  a  stirrer,  a  freezing-bath,  and 
a  thermometer  capable  of  registering  the  hundredths,  or,  better,  the 
thousandths,  of  a  degree  centigrade.  A  lens  is  necessary  to  recognize 
these  minute  variations.  The  test-tube  may  be  made  by  placing  a  flat- 
bottomed  test-tube  one  inch  in  diameter  and  seven  inches  long  within  a 
slightly  larger  tube,  preventing  contact  by  placing  rubber  bands  around 
the  inner  tube.  The  stirrer  is  made  by  bending  a  loop  five-eighths  of 
an  inch  in  diameter  at  a  right  angle  on  the  end  of  a  stiff  wire  of  suita- 
ble length,  to  serve  as  a  handle.  To  the  outer  edge  of  the  loop  is  then 
fastened  with  fine  wire  a  strip  cut  from  the  side  of  a  goose-feather. 
This  must  fit  into  the  inner  tube  with  sufficient  accuracy  to  prevent 
the  clinging  of  ice  crystals  to  its  sides.  The  thermometer  is  placed 
within  the  inner  tube. 

An  approximate  test  of  the  freezing-point  is  made  by  immersing  the 
tube  in  a  freezing-mixture.  A  mixture  of  shaved  ice  and  water  is  then 
prepared  in  a  felt-covered  vessel,  and  enough  salt  is  added  to  reduce 
the  temperature  of  the  slush  to  that  of  the  approximated  freezing-point 
of  the  urine.  The  test-tube  is  filled  one-third  full  of  the  urine  and  placed 
in  the  freezing-mixture  until  the  temperature  falls  to  0.3°  or  0.4°  C. 
below  that  of  the  freezing-point  just  determined.  The  tube  is  then 
transferred  to  the  mixture  of  ice  and  water,  and  a  minute  crystal  of  ice 
is  dropped  into  the  urine  in  order  to  start  the  crystallization.  The  tem- 
perature rises  slightly  as  the  urine  congeals,  and  in  about  one  minute 
it  may  be  read  from  the  thermometer.  In  order  to  secure  the  slightest 
variation  it  is  necessary  to  tap  the  top  of  the  thermometer  with  rapid 
but  delicate  blows.  The  stirrer  must  be  kept  in  motion  during  the  entire 
process. 

BACTERIOLOGICAL  iMETHODS. 

Success  in  bacteriological  work  can  be  attained  only  at  the  expense 
of  considerable  time  and  with  precise  methods.  The  more  elaborate 
investigations  can  be  made  only  in  a  fully  equipped  laboratory,   but 


742  PRACTICE  OF  MEDICINE 

there  is  much  that  can  be  done  in  a  small  way  with  comparatively  lit- 
tle expense  and  in  leisure  moments. 

Preparation  of  the  Specimen.— A  very  small  portion  of  the  culture, 
blood,  pus,  mucus,  or  other  discharge  to  be  examined  is  picked  up  on 
the  platinum  loop  after  it  has  been  passed  through  the  Bunsen  or  al- 
cohol flame,  or  on  a  sterilized  cotton  swab,  and  smeared  on  a  perfectly 
clean  slide  or  cover-glass.  For  permanent  mounts  the  film  should  be 
made  upon  the  cover-glass,  but  for  diagnostic  purposes  the  use  of  the 
slide  is  more  rapid  and  attended  with  less  breakage.  Cultures  should 
be  mixed  with  a  small  drop  of  water  in  order  to  spread  the  bacteria 
over  a  larger  field.  The  film  is  then  allowed  to  dry  in  the  air,  then  fixed 
to  the  glass  by  being  passed  rather  slowly  three  times  through  the 
Bunsen  flame.  It  is  then  ready  to  be  stained.  It  is  always  well  to  ex- 
amine an  unstained  specimen  in  the  hanging  drop  before  drying,  in  order 
to  recognize  motile  bacteria  and  other  peculiarities.  The  hanging  drop 
is  made  by  placing  a  drop  of  the  culture  or  other  fluid,  or  a  drop  of 
water  to  which  the  bacteria  have  been  added,  on  a  cover-glass,  and  in- 
verting it  over  the  depression  in  the  slide  made  for  this  purpose. 

Staining.— For  ordinary  staining,  the  film  is  simply  covered  with  a 
cold  solution  of  one  of  the  anilin  dyes  and  allowed  to  stand  for  five  or 
ten  minutes.  For  this  and  all  manipulations  of  the  cover-glass,  Stewart's 
forceps  (Fig.  50)  or  similar  device  is  exceedingly  convenient. 


Fig.  50. — Stewart's  self  retaining  cover  glass  forceps. 

In  many  instances  the  stain  is  more  quickly  and  more  fully  taken  up 
with  the  aid  of  heat.  The  specimen  is  held  over  the  flame,  at  a  little 
distance,  until  vapor  can  be  seen  arising  from  it;  or  the  cover-glass 
smear  maybe  floated,  film  side  downward,  upon  the  surface  of  the  staining 
fluid  in  a  watch-glass,  while  this  is  held  over  the  flame,  until  evaporation 
can  be  recognized.  The  fluid  should  not  be  raised  to  the  boiling-point. 
After  this  the  specimen  is  thoroughly  washed  in  distilled  water  and  dried, 
first  upon  cigarette-papers  and  then  for  a  few  minutes  in  the  air,  or  it 
may  be  held  at  a  little  distance  from  the  side  of  the  flame.  It  can  then 
be  mounted  in  the  usual  manner  with  a  drop  of  balsam,  or  the  examina- 
tion may  be  made  with  a  drop  of  water. 

Preparation  of  Sections. — When  it  is  desired  to  examine  the  bacteria 
in  the  tissues,  a  small  piece  of  the  organ  must  be  obtained  as  fresh  as 
possible,  and  hardened  in  alcohol  for  a  few  days.  The  pieces  should  riot 
be  more  than  a  centimeter  in  diameter.  After  they  have  become  suifi- 
ciently  hard  they  are  cut  in  the  usual  manner,  in  cork,  liver  hardened 
with  Muller's  fluid,  or  with  the  microtome  after  being  embedded  in  cel- 
loidin  or  paraffin. 

Staining  Solutions.— For  simple  staining,  an  aqueous  solution  of  one 
of  the  anilin  dyes,  as  methylene  blue,  fuchsin,  or  gentian  violet,  is  gen- 


BACTERIOLOGICAL  METHODS      '      "■  743 

erally  employed.  For  convenience,  a  saturated  alcoholic  solution  should 
be  kept  in  stock.  This  is  made  by  placing  in  the  bottle  a  little  more 
of  the  dye  than  will  dissolve  in  enough  alcohol  to  fill  the  bottle.  The 
quantity  of  the  dye  is  usually  about  one-fourth  of  the  capacity  of  the 
bottle.  The  alcohol  is  then  added,  and  the  bottle  is  well  shaken  and  set 
aside  for  24  hours.  A  few  crystals  should  remain  undissolved.  For  use, 
enough  of  the  stock  solution  is  added  to  a  small  bottle  about  two-thirds 
full  of  distilled  water  to  make  a  solution  which  is  barely  transparent. 
The  proportion  is  usually  about  5  c.c.  of  the  saturated  solution  to  95 
c.c.  of  water. 

Some  varieties  of  bacteria  are  slow  to  take  up  the  stains,  and  for 
these  special  solutions  must  be  employed.  In  some  instances  the  stain- 
ing is  so  strongly  retained  that  the  resistance  to  the  action  of  bleaching- 
fluids  is  a  distinguishing  feature  of  the  organism,  as  is  notably  the  case 
with  the  Bacillus  tuberculosis. 

Loffler's  Alkaline  Methylene-Blue  Solution. — The  formula  is  : 

Saturated  alcoholic  solution  of  methylene  blue 30.0 

Solution  of  potassium  hydroxid   in  water  (i  :ioooo) 100. o 

This  solution  is  especially  applicable  to  the  staining  of  the  diphtheria 
bacillus. 

Koch-Ehrlich  Anilin  Water-Fuchsi?i  Solution: 

Anilin-water 50.0 

Saturated  alcoholic  solution  of  fuchsin 5.0 

The  anilin-water  is  made  by  adding  about  5  c.c.  of  anilin  oil  to  100  c.c. 
of  distilled  water,  a  few  drops  at  a  time,  and  shaking  well  after  each 
addition;  then,  after  allowing  the  mixture  to  stand  for  several  hours, 
filtering  it  through  a  moistened  filter-paper.  The  specimen  must  remain 
several  hours  in  this  solution.  Anilin  solutions  of  gentian-violet  or 
anilin  blue  may  be  made  in  the  same  manner. 
Kuhne's  Methylene  Blue: 

Methylene  blue r.5 

Absolute  alcohol 10. o 

Carbolic-acid  solution  (i  :2o)  100. o 

This  stain  requires  about  five  minutes  for  films. 

Carbol-Thionin  Blue. — Thionin'  blue,  i  gm. ;  carbolic-acid  solution 
(i  :4o),  100  c.c.  For  use,  dilute  with  three  times  as  much  water,  and 
stain  from  three  to  five   minutes. 

ZieliVs  Carbol-Fuchsin  Solution: 

Fuchsin 0.5   gm. 

Absolute   alcohol 5.0  c.c. 

Carbolic-acid  solution  (1:20)   50.0  c.c. 

This  solution  may  be  made  also  from  the  stock  solution  of  fuchsin  by 
slowly  adding  it  to  the  5  per  cent  carbolic-acid  solution  until  an  opal- 
escent hue  is  produced  or  until  the  surface  acquires  a  metallic  luster. 
Grain's  lodin  Solution: 

lodin o.  10 

Potassium  iodic! 0.20 

Distilled    water 30.00 

This  solution  is    employed  as  a  bleach  after  staining  with   a  gentian 


744  PRACTICE  OF  MEDICINE 

violet,  especially  for  the  pneumococcus,  and  may  be  followed  with  a 
counter-stain  of  carmin  or  Bismarck  brown.  After  staining  with  the  gen- 
tian-violet solution,  the  specimen  should  be  immersed  for  a  few  moments 
in  the  Gram  solution,  then  washed  in  alcohol.  If  the  cover-glass  still 
retain  a  trace  of  violet  color,  it  must  be  immersed  in  the  iodin  solution 
until  thoroughly  bleached.  The  method  is  valuable  also  for  staining  the 
capsules  of  certain  bacteria. 

Welches  Capsule  Stain. — Another  method  of  staining  the  capsules  of  bac- 
teria thus  enveloped  is  to  cover  the  film  with  glacial  acetic  acid  for  a 
few  seconds,  then  drain  it  off  and  replace  it  with  gentian  violet-anilin 
solution,  repeating  the  application  several  times.  Then  wash  in  a  2  per 
cent  sodium-chlorid  solution,  and  mount  in  the  same  fluid. 

Gabbefs  Blue. — This  is  a  solution  of  2  grams  of  methylene  blue  in  a 
25  per  cent  solution  of  sulphuric  acid.  It  is  employed  chiefly  as  a  com- 
bined bleach  and  counter-stain.  It  should  be  allowed  to  stand  for  sev- 
eral hours  to  become  perfectly  cooled  before  it  is  used.  Specimens  in- 
tended for  permanent  mounts  must  be  thoroughly  washed  after  being 
immersed  in  it.  In  case  the  counter-stain  is  not  sufficiently  deep,  the 
specimen  may  be  immersed  in  the  ordinary  aqueous  solution  of  methyl- 
ene blue. 

Staining  the  Spores.— ^<5<5<?/V  Method.— h.^^'^Xy  one  of  the  anilin  stains 
to  the  film  in  the  usual  manner,  warm  until  steam  rises  over  a  Bunsen 
flame,  and  keep  the  specimen  at  about  this  temperature  for  a  minute  or 
two,  then  wash  and  immerse  in  a  2  per  cent  alcoholic  solution  of  nitric 
acid  until  the  stain  becomes  invisible.  Now  immerse  for  ten  seconds  in 
an  eosin  solution  composed  of  saturated  solution  of  eosin  10  parts, 
distilled  water  90  parts.  The  spores  are  stained  blue,  and  the  bodies  of 
the  bacilli  rose-red. 

Moeller's  method  is  a  little  more  penetrating  than  the  preceding,  and 
it  is  therefore  more  successful  with  some  bacteria.  The  film  should  be 
immersed  for  two  minutes  in  chloroform  before  the  stain  is  applied,  then 
washed  with  water  and  placed  for  from  a  half-minute  to  three  minutes 
in  a  5  per  cent  solution  of  chromic  acid.  It  is  then  washed  in  water  and 
restained  with  Ziehl's  carbol-fuchsin  solution,  warmed  over  the  Bunsen 
flame  for  several  minutes.  The  specimen  is  again  washed  and  decolor- 
ized with  a  3  per  cent  solution  of  hydrochloric  acid  or  5  per  cent  sul- 
phuric acid,  and  finally  stained  for  one  minute  in  methylene  blue.  The 
spores  are  stained  red,  and  the  bacilli  blue. 

Staining  the  Flagella.— A  thin  film  of  a  fresh  18-hour  culture  of  the 
motile  organism  to  be  examined  is  placed  upon  a  perfectly  clean  cover- 
glass  and  allowed  to  dry  in  the  air.  It  is  then  passed  three  times 
through  the  flame  and  immersed  in  a  mordant  solution  of  ferric  alum 
and  fuchsin.  This  solution  is  made  by  adding  to  3  parts  of  a  saturated 
solution  of  alum  i  part  of  diluted  liquor  ferri  sesquichlorid  (1:20  of 
distilled  water).  For  use,  add  to  10  c.c.  of  this  solution  i  c.c.  of  a 
strong  aqueous  solution  of  fuchsin.  The  mordant  must  be  let  stand, 
however,  for  several  days,  and  filtered  before  it  is  used.  The  film  is  im- 
mersed in  it  for  five  minutes,  then  slightly  warmed  and  washed.  It  is 
then  dried,  stained  faintly  with  carbol-fuchsin,  washed,  dried,  and 
mounted.  It  is  sometimes  necessary  to  repeat  the  process  several  times 
before  a  good  result  is  obtained. 


BACTERIOLOGICAL  METHODS  745 

Culture-Media. — For  clinical  work,  the  culture-media  should,  as  a  rule, 
be  purchased  ready  for  use.  The  time  consumed  and  the  difficulties  of 
preparing  them  are  rarely  justifiable  unless  some  special  line  of  investiga- 
tion is  to  be  undertaken.  The  most  generally  useful  media  are  (i) 
nutrient  bouillon,  (2)  bouillon  to  which  has  been  added  one-third  of  its 
volume  of  ascitic  fluid,  (3)  slanting  nutrient  agar,  and  (4)  solidified 
blood-serum.  Of  these,  the  last  meets  the  greatest  number  of  require- 
ments. 

Bouillon. — This  may  be  prepared  directly  from  meat,  or  with  less  diffi- 
culty from  the  beef  extract.  For  the  meat  bouillon,  take  500  grams  of 
lean  beef  or  mutton,  freed  from  fat,  tendon,  and  fiber,  chop  it  fine  and 
soak  it  in  one  liter  of  water  for  24  hours.  During  this  time  it  must 
be  kept  in  a  refrigerator.  Then  squeeze  out  through  muslin  all  the 
juice.  In  this  extract  dissolve  i  o  grams  of  pure  pepton  and  5  grams  of 
pure  sodium  chlorid,  then  boil  in  a  porcelain-lined  pan  for  30  minutes, 
or  until  all  the  albumin  has  been  coagulated.  During  the  boiling,  a  few 
drops  of  a  strong  solution  of  sodium  hydroxid  should  be  added  to  ren- 
der the  fluid  very  faintly  alkaline.  The  water  lost  through  evaporation 
must  be  replaced  so  that  the  quantity  at  the  end  of  the  process  shall 
be  one  liter.  After  the  boiling,  the  fluid  is  filtered  through  paper  into  a 
flask;  this  is  closed  with  a  cotton  plug  and  placed  in  the  sterilizer.  If 
the  Arnold  sterilizer  be  used,  and  it  answers  the  purpose  well,  the  ster- 
ilization must  be  done  by  the  discontinuous  method ;  the  material  must 
be  heated  to  boiUng  (100°  C.)  for  from  15  to  30  minutes  on  three  suc- 
cessive days,  or  for  a  greater  number  of  days  if  the  sterilization  is  found 
to  have  been  incomplete.  If  an  autoclave  be  available,  one  sterilization 
under  an  additional  pressure  of  one  atmosphere  (15  pounds  to  the 
square  inch)  is  sufficient. 

Beef-Extract  Bouillon.— The  formula  for  this  is  :  Beef  extract  (Liebig's 
or  Armour's)  3  grams,  pepton  10  grams,  sodium  chlorid  5  grams, 
water  enough  to  make  i  liter,  and  sufficient  sodium-hydroxid  solution 
to  render  the  bouillon  neutral  or  faintly  alkaline.-  The  processes  of  boil- 
ing, filtration,  and  sterilization  are  the  same  as  those  given  under  the 
preceding  caption. 

Glucose,  lactose,  sucrose,  and  other  saccharine  bouillons  are  made  by 
adding  to  either  of  the  foregoing  bouillon  preparations  i  or  2  per  cent 
of  the  sugar  designated.  Litmus  bouillon  is  made  by  adding  a  small 
quantity  of  litmus  to  the  bouillon. 

Nutrient  Gelatin.— This  is  made  by  adding  to  bouillon  10  per  cent 
of  the  best  sheet  gelatin,  then  boiling,  neutralizing,  and  filtering.  Or 
the  gelatm  may  be  added  to  the  ingredients  of  the  bouillon  in  its  origi- 
nal preparation,  100  grams  being  required  for  the  liter.  It  is  better, 
however,  to  add  the  gelatin  after  the  beef  extract  has  boiled  for  about 
15  minutes.  As  soon  as  the  gelatin  has  become  dissolved,  the  mixture 
is  boiled  vigorously  for  10  or  15  minutes.  Prolonged  heating  of  the 
gelatin  reduces  the  temperature  at  which  it  congeals.  An  attempt  may 
now  be  made  to  filter  the  medium  through  two  or  three  thicknesses  of 
moistened  filter-paper,  pouring  it  down  a  glass  rod.  If  the  filtrate  is  not 
perfectly  clear,  the  liquid  must  be  cooled  to  below  60°  C.  and  mixed  with 
the  albumen  of  one  or  two  eggs  well  beaten  in  50  or  100  c.c.  of  dis- 
tilled water,  then  boiled  for  10  minutes  and  filtered.    The  large  coagula 


746  PRACTICE  OF  MEDICINE 

may  be  removed  with  a  strainer.  The  filter-paper  should  be  folded  into 
small  plaits  or  placed  on  a  wire  frame,  and  the  filtration  is  much  facili- 
tated by  placing  the  filter  and  flask  in  the  sterilizer  or  oven  to  prevent 
cooling  and  solidifying  of  the  gelatin.  After  the  medium  has  been  thor- 
oughly sterilized,  it  is  poured  into  tubes,  5  to  lo  c.c.  in  each;  these 
are  closed  with  cotton  plugs  and  placed  in  the  sterilizer  for  15  minutes 
on  three  succeeding  days. 

Agar  is  made  by  adding,  to  the  liter  of  bouillon  prepared  according 
to  either  of  the  given  formulas,  1 5  grams  of  agar-agar  cut  into  short 
pieces,  boiling  and  filtering  in  the  same  manner  as  in  the  preparation  of 
nutrient  gelatin.  The  bouillon  should,  as  a  rule,  be  diluted  with  an  equal 
quantity  of  water  before  the  agar-agar  is  added,  and  the  boiling  con- 
tinued until  the  quantity  has  been  reduced  to  a  liter,  or  until  the  agar 
has  been  fully  dissolved.  The  scum  should  be  removed  as  it  forms  on 
the  surface.  The  fluid  is  then  cooled,  the  white  of  egg  added  and  again 
boiled,  as  in  the  last  formula.  It  is  finally  filtered,  sterilized,  poured  into 
tubes,  and  again  sterilized.  After  the  last  sterilization  the  tubes  should 
be  laid  in  a  reclining  position,  in  order  that  the  agar  may  solidify  with 
the  proper  slant. 

B/ood-Serum. -^These  tubes  may  be  made  with  either  the  blood  of  cat- 
tle, or  with  human  blood  when  obtainable.  The  blood  should  be  received 
in  a  tall  glass  jar  and  kept  in  a  cool  place  for  from  24  to  48  hours, 
in  order  to  permit  complete  separation  of  the  clot  and  serum  to  take 
place.  The  serum  is  then  removed  from  the  jar,  with  a  pipette  or  by 
decanting,  and  poured  directly  into  the  culture-tubes.  The  tubes  are 
then  placed  at  a  proper  slant  in  the  sterilizer  and  carefully  raised  to  a 
temperature  of  90°  C.  until  the  serum  has  become  thoroughly  coagulated. 
If  raised  to  the  boiling-point,  the  surface  is  rendered  rough  by  the 
formation  of  bubbles.  After  the  coagulation  has  been  completed,  the 
tubes  can  be  raised  to  an  upright  position  and  the  sterilization  contin- 
ued on  succeeding  days  as  with  the  other  media. 

Lofflhr's  Blood-Serum. — This  is  prepared  in  the  manner  just  described, 
except  that  one  part  of  bouillon  containing  i  per  cent  of  glucose  is 
added  to  3  parts  of  beef  blood-serum  before  the  coagulation. 

Potato. — After  washing  and  paring,  the  potatoes  are  cut  into  pieces 
of  proper  size  to  be  placed  in  the  tubes,  and  with  a  beveled  side  to 
correspond  to  the  slant  given  to  the  other  media.  The  pieces  are  then 
passed  into  the  tubes,  a  little  space  being  left  at  the  bottom  for  the 
accumulation  of  water.  The  tube  is  closed  with  cotton  and  sterilized 
in  the  ordinary  way. 

M/'/k  is  sometimes  emploj^ed  as  a  culture-medium,  especially  for  the 
study  of  bacteria  that  coagulate  casein  or  develop  acids.  For  the  latter 
purpose  just  enough  litmus  solution  should  be  added  to  the  milk  to 
give  it  a  pale  blue  tinge.  The  milk  is  then  poured  into  tubes  and  ster- 
ilized by  the  three-day  method. 

Making  Cultures.— Cultures  from  the  living  patient  should  be  made 
at  the  bedside ;  for  if  the  specimen  be  transported  to  any  distance,  many 
of  the  bacteria  will  die,  and  there  is  greater  danger  of  contamination  of 
the  specimen.  Cultures  from  the  dead  body  should  be  made  at  the 
earliest  possible  moment  after  death,  and  directly  from  the  body  to  the 
culture-medium.      For    inoculating   the    bouillon -culture    the    platinum 


BACTERIOLOGICAL  METHODS  747 

loop  is  most  suitable,  but  solid  media  may  be  inoculated  with  either  the 
loop  or  a  sterilized  cotton  swab.  Only  heat  is  to  be  used  to  sterilize 
the  loop  or  swab;  chemicals  must  not  be  employed.  The  bacteria  are 
transferred  by  lightly  touching  the  wire,  after  it  has  been  passed  through 
the  flame,  to  the  culture  or  other  source  from  which  they  are  to  be  ob- 
tained, and  rubbing  this  gently  over  the  culture-medium.  For  the  isola- 
tion of  different  species,  the  plate-culture  affords  the  most  satisfactory 
results,  since  the  growth  of  different  colonies  can  be  more  readily  recog- 
nized and  more  easily  transferred  to  tubes  for  the  purpose  of  further 
study.  A  pure  culture  can  seldom  be  obtained  directly  from  tube-cultures. 
After  a  pure  culture  has  been  obtained,  however,  further  propagation 
may  be  continued  indefinitely  by  means  of  the  tubes. 

Plate-Cultures. — These  are  made  by  inoculating  nutrient  media  spread 
upon  glass  plates  or  in  shallow  dishes  (Petri  dishes).  Two  methods 
are  employed.  In  the  first  the  matter  containing  bacteria  is  streaked 
over  the  surface  after  the  medium  has  hardened;  in  the  other,  the  ma- 
terial is  mingled  with  the  nutrient  substance  while  it  is  still  warm  and 
in  a  fluid  state,  but  cool  enough  to  exert  no  harmful  influence  upon  the 
organisms  introduced  into  it.  Both  agar  and  gelatin  plates  are  made 
use  of.  Nutrient  i  per  cent  agar  begins  to  solidify  at  about  36°  C, 
while  the  10  per  cent  gelatin  solidifies  at  a  temperature  of  23°  C.  The 
former  is  therefore  used  for  cultures  to  be  kept  at  the  temperature  of  the 
body,  and  the  latter  for  those  requiring  room  temperature.  In  inoculat- 
ing agar  plates  by  the  method  of  mingling  the  substance  containing  the 
bacteria  with  the  medium,  care  must  be  taken  in  the  first  place  not  to 
add  the  contaminated  matter  to  the  agar  while  it  is  too  hot,  and  on  the 
other  hand  not  to  permit  the  culture-medium  to  become  partially  solidi- 
fied before  the  mixing  has  been  accomplished.  The  bacteria  should  be  added, 
as  a  rule,  when  the  medium  is  at  about  40°  C.  Every  precaution  against 
contamination  must  be  exercised.  The  thermometer  must  be  sterile, 
and  the  Petri  dishes  must  be  opened  only  long  enough  to  permit  the 
pouring  in  of  the  culture.  As  the  fluid  solidifies,  the  organisms  are 
sealed  within  it,  and  after  a  proper  time  each  will  develop  a  colony  if 
the  conditions  for  its  growth  have  been  right.  The  number  of  colonies, 
as  well  as  the  different  varieties  of  bacteria,  should  be  carefully  deter- 
mined. 

In  making  primary  cultures  for  the  purpose  of  isolating  a  micro- 
organism whose  culture  peculiarities  are  not  known,  several  plates  or 
tubes  and  several  different  media  should  be  inoculated,  using  different 
quantities  of  the  material  in  the  different  plates.  On  the  solid  media 
it  is  well  to  make  both  the  stroke  and  the  stab  culture. 

The  stroke  culture  is  made  thus  :  Sterilize  a  straight  platinum  needle 
in  the  flame  and  touch  it  to  the  substance,  pus,  organ  or  tissue,  to  be 
investigated;  then,  after  removing  the  cotton  plug  from  a  fresh  culture- 
tube  held  on  a  slant,  draw  the  needle  in  a  straight  line  over  the  surface 
of  the  medium,  and  immediately  replace  the  cotton. 

The  stab  culture  is  made  in  the  same  manner,  except  that  the  needle 
is  thrust  down  through  the  center  of  the  medium  nearly  to  the  bottom 
of  the  tube.     Media  for  this  purpose  are  solidified  in  an  upright  position. 

The  principal  features  to  be  observed  in  the  stroke  culture  are  the 
extent  and  form  of  the  growth,  the  shape  of  the  margins,   its  color, 


748  PRACTICE  OF  MEDICINE 

and  whether  it  is  flat  or  raised,  clear  or  opaque.  In  the  stab  culture 
the  principal  features  to  be  noted  are  the  extent  of  the  growth  along 
the  entire  line  of  inoculation  or  only  at  the  surface,  its  abundance,  its 
color,  and  whether  the  medium  has  been  altered  in  color,  odor,  or  con- 
sistence. If  hquefaction  occurs  in  gelatin  cultures,  one  should  observe 
whether  this  takes  place  at  the  surface  or  along  the  hne,  and  the  form  of 
the  area  that  has  undergone  liquefaction. 

EXAMINATION  OF  SPUTUM. 

Microscopic  examination  of  the  sputum  is  of  value  not  merely  for  the 
discovery  of  bacteria,  but  for  the  recognition  of  various  other  elements 
that  may  be  present  in  it.  Fragments  of  tissue  are  found,  either  as  sep- 
arate filaments  or  in  a  more  or  less  complete  alveolar  arrangement, 
when  there  are  disintegrating  lesions  of  the  lungs  or  bronchi.  Very 
rarely  the  cellular  structure  of  neoplasms  can  be  recognized.  Cursch- 
mann's  spirals  and  the  Charcot-Leyden  crystals  are  often  found  in  con- 
nection with  asthma.  Hematoidin  plates  and  crystals  are  occasionally 
found  after  hemiorrhagic  affections.  Cholesterin,  leucin,  tyrosin,  calcium 
carbonate  and  oxalate,  the  triple  phosphate,  and  other  crystals  have 
been  occasionally  discovered. 

The  Tubercle  Bacillus.— The  most  frequent  and  probably  the  most  im- 
portant object  of  sputum  examination  is  to  determine  the  presence  or 
absence  of  the  Bacillus  tuberculosis.  For  this  purpose,  a  small  particle 
of  sputum  is  spread  upon  a  cover-glass  or  slide  in  the  usual  manner, 
passed  three  times  through  the  Bunsen  flame,  and  stained.  In  selecting 
the  specimen,  a  small,  white,  cheesy  mass  should  be  picked  up  with  the 
loop,  or  if  such  particles  are  not  found,  an  otherwise  representative  por- 
tion of  the  sputum  should  be  selected.  There  are  three  principal  methods 
of  staining.  The  carbol-f  ichsin  method  is  probably  more  generally  used 
than  any  other.  The  formula  for  this  solution  has  been  given  on  page 
743.  After  the  film  has  been  made  and  fixed  by  heat,  it  is  covered 
with  the  solution  and  held  over  the  Bunsen  flame  for  two  or  three 
minutes  at  such  a  distance  that  vapor  rises  without  ebullition.  The 
coloring  fluid  is  then  washed  off"  with  water;  next  the  specimen  is  de- 
colorized in  a  I  per  cent  solution  of  hydrochloric  acid  in  70  per  cent 
alcohol,  or  in  2  per  cent  nitric  acid-alcoholic  solution.  The  decolor- 
ization  is  stopped  by  quickly  washing  the  specimen  in  water  immedi- 
ately upon  the  disappearance  of  all  perceptible  color.  If  it  be 
thought  necessary  to  exclude  the  smegma  bacillus,  the  cover-glass  is  now 
immersed  for  a  minute  in  pure  alcohol.  The  film  may  then  be  given 
a  counter-stain  with  the  simple  solution  of  methylene  blue,  applied 
cold,  after  which  it  is  ready  for  the  final  washing  with  water,  dry- 
ing, and  mounting.  By  this  method  the  bacilli  are  stained  a  brilliant 
red,  other  bacteria  and  cellular  elements  blue. 

Gabbefs  Method. — This  method  yields  excellent  results  and  is  preferred 
for  routine  work  on  account  of  the  greater  simplicity  of  the  manipula- 
tions. The  sputum  is  spread,  fixed,  stained  with  the  carbol-fuchsin  solu- 
tion, and  washed  in  water,  just  as  in  the  preceding  method.  It  is  then 
decolorized  and  counter-stained  by  means  of  Gabbet's  combined  solution 
(see  p.   744),  allowing  the  solution  to  act  from  15  seconds  to  a  minute, 


EXAMINATION  OF  SPUTUM  749 

or  until  all  trace  of  the  red  stain  has  vanished  and  the  film  has  acquired 
a  pale  blue  tinge.  The  specimen  is  then  washed  and  mounted  in  the 
usual  manner.  The  result  is  the  same  as  that  of  the  preceding  method. 
This  method  has  the  advantage  that,  after  a  few  trials,  a  uniform  regu- 
lation of  time  can  be  adopted  with  a  greater  certainty  of  good  results. 
WTien  the  counter-stain  does  not  act  so  deeply  as  is  desirable,  the  speci- 
men can  be  treated  for  a  few  moments  with  the  akaline  methylene-blue 
solution. 

Koch-Ehrlich  Method. — The  only  essentially  different  feature  in  this 
method  is  the  use  of  the  anilin  water-fuchsin  solution.  The  cover-glass 
is  floated,  film  downward,  on  the  surface  of  a  small  quantity  of  the  solu- 
tion in  a  watch-glass  held  over  the  flame  for  about  two  minutes,  the 
solution  being  raised  almost  to  the  point  of  boiling.  The  specimen  is 
then  decolorized  in  3  per  cent  hydrochloric  acid  in  70  per  cent  alcohol, 
washed,  dried,  and  mounted.  Better  results  are  sometimes  obtained  by 
allowing  the  stain  to  act  for  several  hours,  after  having  been  warmed. 

Staining  the  Bacillus  in  Sections.— The  sections  should  be  as  thin  as 
the  tissues  will  permit.  They  may  be  stained  in  the  same  solutions  as 
are  employed  for  the  films,  but  at  a  lower  temperature. 

Ehrlich  Method. — The  sections  are  placed  in  anilin-fuchsin  solution  and 
allowed  to  stand  for  from  two  to  twelve  hours,  then  decolorized  for 
about  30  seconds  in  a  10  per  cent  solution  of  nitric  acid  and  washed 
in  60  per  cent  alcohol  until  the  free  coloring  matter  has  been  removed. 
They  are  then  counter-stained  for  two  or  three  minutes  in  a  saturated 
aqueous  solution  of  methylene  blue,  washed  in  water,  dehydrated  with 
absolute  alcohol,  cleared  in  xylol  or  cedar  oil,  and  mounted  in  xylol 
balsam. 

Carbol-Fuchsin  Method. — The  sections  are  stained  in  the  carbol-fuchsin 
solution  warmed  to  not  more  than  50°  C.  and  allowed  to  stand  in  the 
fluid  for  an  hour.  They  are  then  decolorized  in  5  per  cent  sulphuric 
acid,  washed  in  70  per  cent  alcohol,  counter-stained  as  in  the  Ehrlich 
m.ethod,  washed,  dehydrated,  clarified,  dried,  and  mounted. 

Examination  of  Water  and  Other  Fluids.— The  number  of  bacilli  in 
water,  milk,  and  other  liquids  can  be  approximately  determined  by 
means  of  plate-cultures.  A  definite  quantity  of  a  representative  por- 
tion of  the  fluid  to  be  tested,  either  in  its  purity  or  diluted  with  steril- 
ized distilled  water  in  case  it  is  highly  contaminated,  is  added  to  a 
liquefied  culture-medium,  poured  into  the  Petri  dish,  allowed  to  harden 
and  kept  at  the  proper  temperature  until  growth  can  be  recognized. 
The  number  of  colonies  is  then  counted  with  the  aid  of  a  lens.  Each 
colony  represents  an  individual  micro-organism,  and  the  number  of  colo- 
nies, therefore,  corresponds  to  the  number  of  bacteria  in  the  original 
quantity  of  fluid.  Tufts  of  bacteria  may,  of  course,  be  counted  as  single 
germs  by  this  method,  but  the  result  is  sufficiently  accurate  for  practical 
purposes. 


INDEX 


Abasia,  701 
Abdominal  typhus,  47 
Abscess,  atheromatous,  371 

of  brain,  667 

in  scarlatina,  104 

of  liver,   524 

of  lung,  413 

of  mediastinum.  380 

of  spleen,  314 

pancreatic,  540 

perinephric,  578 

retropharyngeal,  438 

subphrenic,  522 
Abscess-formation,  after  pneumonia,  118 
Abscesses,  calcification  of,  26 

metastatic,  in  gangrene  of  the  lung,  414 

mihary,  in  pyemia,  150 
Acanthocephala,  279 
Acarus  folliculorum,  287 

of  adobe  itch,  287 

scabei,  287 
Acephalocysts,  284 
Acetanilid,  test  for,  735 
Acetic  acid  in  urine,  560 
Aceton  in  diabetic  urine,  599 
Achylia  gastrica,  471 
Acid  intoxication,  6 
Acid  pus  in  pyelitis,  575 
Acromegaly,  705 
Actinomycosis,  235 

of  lung,  235,  416 
Acute  yellow  atrophy  of  liver,  515 
Addison's  disease,  310 
Adenin,  6 
Adenitis  in  chronic  tuberculosis,  196 

in  diphtheria,   131,   132 

in  scarlatina,  104 

malignant,  94 

tubercular,  182 
Adiposis  dolorosa,  604 
Adobe  itch,  acarus  of,  287 
Adrenals,  lesions  of,  in  diabetes,  596 
Aerobes,  34 

Agar  culture-media,  746 
Agglutinins.  41 
Agraphia,  675 
Ague,  239 
Ague  cake.  242 
Ainhum,  706 
Akoria,  475 

Albumin  in  stomach-contents,  test  for,  721 
Albumin-tests,  7;io 


Albuminuria,  555 

cyclic,  555 

febrile,  556 

functional,  555 

hemic,  556 

in  diphtheria,  132,  136 

in  erysipelas,  153 

in  exophthalmic  goiter,  319 

in  yellow  fever,  92 

intermittent,  555 

neurotic,  556 

of  adolescence,  556 

paroxysmal,  555 

physiological,  555 

with  definite  kidney  lesions,  556 

without  definite  kidney  lesions,  555 
Albumose  in  stomach-contents,  721 
Albumosuria,  558 
Alcoholic  cirrhosis  of  liver,  517 
Alcoholism,  605 

in  erysipelas,  152 

in  etiology  of  pneumonia,  117 

in  etiology  of  tuberculosis,  175 
Alexins,  40 

Alkapton,  test  for,  731 
Alkaptonuria,  559 
Allantiasis,  614 
Alopecia  after  typhoid  fever,  67 

in  syphilis,   164 
Amaurotic  family  idiocy,  652 
Amblyopia,  malarial,  247 

tobacco,  624 
Ameba  coli,  examination  of  stools  for,  726 

dysenterise,  252 
Amebas  in  hepatic  abscess,  524 
Amphistomum  hominis,  270 
Amygdalitis,  439 

Amylaceous  bodies  in  myelitis,  639 
Amyloid  disease,  23 

in  syphilis.   165 

of  intestine,  489 

of  spleen,  315 

in  tuberculosis,   195 

liver,  527 

substance,  composition  of,  23 
Amyotrophic  lateral  sclerosis,  645 

gait  of,  646 
Anacidity  of  stomach,  nervous,  471 
Anaerobes,  34 
Anasarca,   12 

Anatomical  sediments  in  urine,  y^'^S 
Anemia,  289 


75- 


INDEX 


Anemia,  bothriocephalus,  381 

brickmakers',  275 

collateral,  11 

general,  290 

idiopathic,  290 

in  cancer  of  the  stomach,  465 

in  chronic  tuberculosis,  196 

in  lead-poisoning,  611 

in  syphilis,   164 

in  typhoid  fever,  78 

in  whooping-cough,  143 

local,   II 

mountain,  227,  275 

of  brain,  660 

of  spinal  cord,  6;^^ 

pernicious,  290 

primary,  290 

progressive,  pernicious,  290 

secondary,  294 

splenic,  315 

toxemic,  294 
Anesthesia  dolorosa,  641 
Aneurism,  2,ys 

miliary,  of  brain,  659 

mycotic,  374 

of  abdominal  aorta,  ;iyy 

of  aorta,  374 

of  cerebral  arteries,  659 

of  heart,  361 

of  other  vessels,  378 

symptoms  of  rupture  in,  375 
Angina,  acute  or  catarrhal,  437 

chronic,  438 

maligna,   129 

pectoris,  366 

theories  of,  367 
treatment  of,  368 
toxic,  368 
vasomotor,  367 
Angiocholitis,  532 

acute  catarrhal,  533 

chronic  catarrhal,  534 

epidemic,  533 

suppurative  and  ulcerative,  534 
Angioma  of  liver,  530 
Angioneurotic  edema,  703 
Anguillula  stercorals  and  intestinalis,  278 
Angular  gyrus,  lesions  of,  625 
Anhydremia,  9 
Animal  heat,  sources  of,   19 

parasites,  diseases  due  to,  239 
in  urine,  739 
Animals  and  the  plague,  94 
Ankylostomiasis,  275 
Ankylostomum  duodenalis,  275 
Anopheles  of  malaria,  240 
Anorexia,  475 

in  typhoid  fever,  59 
Anosmia,  624 

in  rhinitis,  384 
Anthracosis,  407 
Anthrax,  232 

external,  233 

internal,  234 


Anthrophobia,  697 
Anti-  bodies,  40 

origin  of,  41 
Antipyrin,  test  for,  735 
Antistreptococcus-serum  in  sepsis,  149 
Antitoxin,  origin  of,  41 
Antitoxin  eruptions,  140 
Antitoxin  treatment  (see  Serum  treatment) 
Antitoxins,  artificial,  43 
Antrum,  involvement  of,  in  diphtheria,  134 
Anuria,  555 
Aorta,  aneurism  of,  374 

large  solitary  tubercle  of,  206 
Aortic  incompetency,  342 

stenosis,  346 
Aortitis,  369 
Aphasia,  674 

after  typhoid  fever,  64 

in  cerebrospinal  meningitis,  113 

in  pneumonia,   125 

ataxic,  674 

motor,  674 

sensory,  675 

transcortical,  motor,  674 
Aphonia  in  mediastinal  disease,  379 
Aphthge  of  Bednar,  431 
Aphthous  fever,  237 
Aplasia,  21 
Apoplexy,  661 

in  myocarditis,  360 

spinal,  636 
Appendicitis,  489 

catarrhal  type  of,  490 

chronic,  494 

gastrointestinal  disturbances  in,  493 

indications  for  operation  in,  497 

micro-organisms  in,  492 

necrotic  type  of,  492 

obliterans,  491 

perforation  in,  492 

recurrent,  495 

ulcerative  type  of,  491 
Appendix,  actinomycosis  of;,  491 

normal,  489 
Apraxia,  675 
Aprosexia,  440 
Aptyalism,  436 
Arachnids,  parasitic,  287 
Aran-Duchenne  muscular  atrophy,  645 
Argyll  Robertson  pupil,  625 

in  chronic  meningoencephalitis,  670 

in  locomotor  ataxia,  649 
Argyria,  27 
Arithmomania,  682 
Arm,  lesions  of  nerves  of,  633 
Arrhythmia  of  heart,  364 
physiological,  365 
Arsenical  poisoning,  613 
Arteries,  diseases  of,  369 
Arteriosclerosis,  370 

in  alcoholism,  607 

in  gout,  590 

of  brain,  658 

of  spinal  cord,  638 


INDEX 


753 


Arteritis  in  pyemia,   1 50 

Arthralgia  due  to  lead  intoxication,  612 

Arthritis,  chronic  rheumatic,  581 

deformans,  581 
in  children,  583 
monarticular  type  of,  583 
multiple,  progressive  type  of,  582 
theories  of,  581 

gonorrheal,   161 

in  cerebrospinal  meningitis,   113 

in  scarlatina,   104 

in  typhoid  fever,  68 

rheumatoid,  581 
Ascariasis,  270 
Ascaris  alata,  271 

lumbricoides,  270 

mystax,  271 
Ascites,  12,  549 

adipose,  550 

chylous,  277 

in  chronic  gastritis,  451 

in  cirrhosis  of  liver,  519 

in  mediastinal  disease,  379 

leukemic,  297 
Aseptic  fever,   147 
Asiatic  cholera,  86 
Aspiration  pneumonia,  403 

in  diphtheria,   135 
Astasia,  701 
Asthma,  bronchial,  394 

cardiac,  treatment  of,  351 

spasmodic,  394 

thj'micum    (see    Laryngismus    stridu- 
lus), 386 
Ataxia,  Friedreich's,  652 

hereditary,  652 

locomotor,  647 

static,  653 
Ataxic  paraplegia  (Cowers),  652 
Atelectasis,  412 
Atheroma,  370 
Athetosis,  682 

after  cerebral  hemorrhage,  664 
Athlete's  heart,  342 
Athyria,  320 
Atony  of  stomach,  474 
Atrophy,  20 

brown,  12 

local,  21 

neuropathic,  21 

of  muscles  in  acufee  rheumatism,  158 

of  optic  nerve,  624 
after  mumps,   145 

of  stomach,  450 

physiological,  21 

progressive  muscular,  645 
Auditory  nerve,  disease  of,  628 
Aura,  epileptic,  685 
Autoinfection     in    chronic    tuberculosis, 

194 
Autoinoculation  in  tuberculosis,   173 
Autointoxication,  6 
Autumnal  catarrh,  383 
fever,  47 


Baccelli"s  sign  in  pleurisy,  420,  422. 
Bacilli,   33 

in  urine,  740 
Bacillus  coli  communis,  492 
diphtherige,  in  noma,  432 

in  pneumonia,   116 
dysenteric,  in  gastroenteritis,  481 
icteroides,  89 
lepras,  220 
of  dysentery,  250 
of  Lustgarten,  162 
of  Nocard,   236 
of  sputum  septicemia,   142 
of  tetanus,   223 
pestis  (Kitasato),  94 
pneumonige,  in  bronchopneumonia,  402 
proteus  fluorescens,  225 
tuberculosis,   169 

distribution  of,   170 
in  pleurisy,  417,  418 
in  sputum,  748 

relation  of,  to  ray  fungus,   170 
saprophytic  existence  of,   170 
virulence  of,   170 
typhosus,  49 
Bacteremia,  146 
Bacteria,  chemical  action  of,  34 
chemical  composition  of,  33 
in  cancer  of  stomach,  463 
in  cholelithiasis,  536 
in  urine,  740 
morphology  of,  32 
motility  of,  34 

of  sepsis,   146  I 

pathogenic,  39 
structure  of,  32 
vital  phenomena  of,  33 
Bacteriological  methods,  741 
Bacteriology,  general,  32 
Bacteriolysins,  41 
Balantidium  coli,  269 
Ball-valve  action  of  gall-stones,  538 
''Balloon  man"  of  Formad,  508 
Banting  method  in  obesity,  604 
Barlow's  disease,  308 
Barrel-chest  due  to  tonsilitis,  441 
Basedow's  disease,  317 
Basilar  meningitis,  179,  658 
Battledore  hands,  705 
Bedbug  as  a  parasite,  288 

in  etiology  of  relapsing  fever,  81 
Bedsores  in  cholera,  88 

in  typhoid  fever,  66,  yj 
Bell's  mania,  677 
paralysis,   627 
Bence  Jones  reaction,  558 
Beriberi,  98 

Bigemism  of  heart,  364 

Bile-acids,  tests  for,  734 

ducts,  cancer  of,  539 

chronic  obstruction  of,  538 
passages,  diseases  of,  530 
salts,  retention  of,  6 
Biliary  colic,  537 


754 


INDEX 


Bilious  remittent  fever,  246 

typhoid,  8 1 
Biuret  reaction,  728,  730 
Black  death,  94 
fever,  227 
Jack,  89 
measles,  108 
vomit,  89,  92 
Bladder,  calcification  of,  26 

tuberculosis  of,  210 
Blepharitis  in  measles,  108 
Blindness  after  scarlatina,  104 

from  cerebrospinal  meningitis,   113 
in  smallpox,  262 
Blood,  bacteriological  examination  of,  718 
-changes  in  disease,  9 
-count,  711 
-diseases  of  the,  289 
-dust,  Muller's,  719 
examination  of,  711 
features  of,  in  acute  nephritis,  565 
in  appendicitis,  494 
in  cancer  of  liver,  528 
in  chlorosis,  293 
in  diphtheria,  132 
in  gout,  589 
in  lead-poisoning,  6ri 
in  pernicious  anemia,  291 
in  pneumonia,  122 
in  pseudoleukemia,  301 
in  pyemia,  151 
in  rheumatism,  156 
in  splenomyelogenous  leukemia,  298 
in  typhoid  fever,  51 
flukes,  269 
in  sputum,  199 
in  the  urine,  tests  for,  738 
-plates,  719 
-poisoning,  146 
pressure,  10 

-serum  culture-media,  746 
specific  gravity,  test  for,  717 
-specimen,  staining  of,  715 
tests  for,  718 
Blue  disease,  227 

line  in  lead-poisoning,  '611 
Boas-Oppler  bacillus  in  cancer  of  stomach, 

466 
Bottger's  test  for  sugar,  732 
Bone-marrow,     condition    of,  in   leukemia, 

296 
Bones,  lesions  of,  in  typhoid  fever,  67 
Bothriocephalus  latus,  280 
Botulismus,  614 
Bouillon  culture  media,  745 
Bowel,  constriction  of,  498 
obstruction  of,  498 
ulcers  of,  487 
Brachial  plexus,  diseases  of,  633 
Brachycardia,  366 
Bradycardia,  366 

in  influenza,  82,  83 

in  disease  of  pneumogastric,  630 

in  typhoid  fever,  58 


Brain,  abscess  of,  667 

after  typhoid  fever,  64 
affections   of  blood-vessels  and  circula- 
tion of,  658 
anemia  of,  660 
cysticerci  in,  282 
diseases  of,  656 
edema  of,  661 

embolism  and  thrombosis  of,  666 
■  fever,  b"^"] 
hyperemia  of,  661 
inflammation  of,  667 
large  solitary  tubercle  of,  205 
lesions  of,  in  cerebrospinal  meningitis, 

III 
-sand,  26 
sclerosis  of,  671 
tumors  and  cysts  of,  672 

localizing  symptoms  of,  6^2) 
Brand  method  of  hydrotherapy,  74 

contraindications  to,  74 
Breakbone  fever,  84 
Breast  pang,  366 

Brick-dust  sediment  in  lithemia,  558 
Brickmaker's  anemia,  275 
Bright's  disease  (see  Nephritis),  acute,  563 

chronic,  567 
Bromatotoxismus,  614 
Bromin,  test  for,  735 
Bronchial  asthma,  394 
flukes,  269 

glands,     condition     of,      in     broncho- 
pneumonia, 193 
in  measles,  108 
in  tubercular  adenitis,  1S3 
in  whooping-cough,  143 
Bronchiectasis,  393 

in  chronic  tuberculosis,  194 
Bronchi,  diseases  of  the,  387 
Bronchitis,  acute,  387 
capillary,  402 
croupous,  391 
exudative,  391 
fetid,  390 
fibrinous,  391 
in  diphtheria,  135 
in  emphysema,  410 
in  typhoid  fever,  62 
in  whooping  cough,  143 
obliterative,  393 
plastic,  391 

pseudomembranous,  391 
putrid,  390 
Bronchocele,  316 
Bronchorrhea,  390 
Bronchopneumonia,  402 

in  cerebrospinal  meningitis,    ni,    113 
in  diabetes,  599 
in  diphtheria,   131,  135 
in  influenza,  83 
in  measles,  108 
in  noma,  433 
in  whooping  cough,  143 
Bronchopulmonary  hemorrhage,  399 


INDEX 


755 


Brown  atrophy  of  the  heart,  361 
Brown-Sequard  theory  of  uremia,  560 
Bruce,  micrococcus  of,  97 
Bruit,  aneurismal,  376 

de  diable,  in  exophthalmic  goiter,  319 
Brunner's  glands,  cystic,  inpeptic  ulcer,  459 
Bubo,  climatic,  97 

malarial,  97 

primary,  of  plague,  95 

secondary,  of  plague,  95 
Bubonic  plague,  94 
Buccal  psoriasis,  435 
Buhl's  disease,  305 
Bulbar  paralysis,  progressive,  646 
Bulimia,  475 

in  diabetes,  59S 
Burns's  (Allan)  theory  of  angina,  ^6y 
Bursitis,  gonorrheal,   162 
Butyric  acid  in  urme,  560 

Cachexia  in  amyloid  kidney,  ^7^ 

in  cancer  of  liver,  528 

in  cancer  of  stomach,  465 

malarial,  243,  247 

saturnine,  611 

strumipriva,  320 
Cadaverin,  6 
Caisson  disease,  638 
Calcareous  particles  in  sputum.  199 
Calcification,  25 

of  cardiac  valves,  335 

of  gall-bladder,  538 

results  of,  25 

universal,  25 
Calcium  oxalate  in  urine,  yT,y 
Calculi,  bihary,  576 

calcium  oxalate,  576 

coral,  576 

pancreatic,  543 

phosphatic,  576 

uric  acid,  576 
Calculus,  renal,  576 

vesical,  578 
"Calm"  in  yellow  fever,  91 
Camp  fever,  78 
Cancer  (see  Carcinoma) 
Cancrum  oris,  432 
Canter  rhythm  of  heart,  364 
Capsulitis,   chronic  hepatic,  523 
Caput  Medusae  in  ascites,  550 

in  cirrhosis  of  liver,  519 
Caput  quadratum  in  rickets,  594 
Carbol-fuchsin  solution,  743 
Carbol-thionin  solution,  743 
Carbonates,  test  for,  730 
Carbuncles  in  diabetes,  599 
Carcinoma,  diffuse,  of  stomach,  466 

of  adrenal  bodies,  311 

of  esophagus,  443 

of  gall-bladder  and  bile-ducts.  539 

of  liver,   528 

of  lung,  415 

of  pancreas,  543 

of  peritoneum,  549 


Carcinoma,  of  spleen,  315 

of  stomach,  463 
Cardialgia  in  chronic  gastritis.  45;! 
Carphology,  64 
Caseation,  28 

Caseous  pneumonia,   176,   192 
Casts,  urinary,  73S 
Cataract  in  diabetes,  600 
Catarrh,  acute  gastric,  447 

acute  intestinal,  476 

acute  nasal,  381 

autumnal,  383 

chronic  gastric,  450 

chronic  intestinal,  478 

chronic  nasal,  382 
Cauda  equina,  lesions  of,  655 
Celiac  axis,  aneurism  of,   T,y& 

disease,  485 
Cells,  formative,  in  regeneration,  31 
Cellulitis,  cervical,  in  scarlatina,   102,   104 

of  neck,  434 
Cephalodynia,  586 
Cercomonas  coli  hominis,  268 

intestinalis,  268 
Cerebellum,  tuberculosis  of,  205 

tumor  in,  673 
Cerebral  hemorrhage,  66 1 
Cerebritis,  acute,  667 
Cerebrospinal  fever,  1 1 1 

meningitis,  1 1 1 
abortive,  113 
chronic,  113 
intermittent,  113 
malignant,  113 
varieties  of,   113 
Cervical  plexus,  disease  of,  632 
Cestodes,  7 

diseases  caused  by,  279 
Chalcicosis,  407 
Chancre,   163 
Chancroid,  166 
Charbon,   232 
Charcot  joint,  649 
Charcot-Leyden  crystals,  396 

in  tubercular  sputum,  205 
Charcot's  crystals  in  leukemic  blood,    296 
Chemosis,  29 

Chest,  barrel-shaped,  409,  411 
Cheyne-Stokes   respiration   in  acute  tuber- 
culosis, 178 

in  cerebrospinal  meningitis,  112 
in  cholera  infantum,  483 
in  chronic  myocarditis,  360 
in  uremia,   561 
Chicken-breast  in  rickets,  594 
Chickenpox,  266 
Chick-pea- vetch  poisoning,  615 
Chill,  congestive,  246 

de  Luca's  theory  of,  20 

in   acute  pneumonic  tuberculosis,  193, 
194 

in    pneumonia,   119 
Chills  and  fever,  239 

in  cholelithiasis,  537 


756 


INDEX 


Chills  in  chronic  tuberculosis,  196 

in  pyemia,   151 

in  typhoid  fever,  51,  57 
Chloral  habit,  610 
Chloranemia,  292 
Chlorids  in  urine,  test  for,  729 
Chloroma,  299 
Chlorosis,  292 

Egyptian,  275 
Choked  disk,  624 
Cholangitis,  acute.  532 

chronic.  534 

infectious,  in  cholelithiasis.  53S 
Cholecystitis,  acute  infectious,  535 
Cholelithiasis,  536 
Cholemia,  6 
Cholera,  86 

infantum.  483 

morbus,  480 

nostras,  480 

sicca,  87 

spirillum  of,  86 
Cholerine,  88 
Chondroblasts,  32 
Chorea,  acute,  680 

after  scarlatina,   104 

chronic,  682 

hysterical,  682 

in  acute  rheumatism,   158 

insaniens,  681 

major,  682 

minor,  680 

paralytic,  681 

saltatory,  682 
Choreoid  affections,  682 
Choroiditis  in  syphilis,  164. 
Chromatopsia  in  sunstroke,  617 
Chvostek's  symptom  in  tetany,  68§ 
Chylopericardium,  329 
Chyluria,  558 

in  filariasis,  277 
Cimex  lectularius,  28R 

Circulation,  changes  in,  during  disease,  lo 
Circulatory  system,  diseases  of,  322 
lesions  of.  in  tj'phoid  fever,  57 
tuberculosis  of.  205 
Circumflex  nerve,  disease  of,  633 
Cirrhoses  of  the  liver.  517 
Cirrhosis,  atrophic,  of  liver,  517 

anastomotic    communications     in, 

519 

biliary,  521 

capsular,  523 

fatty,  of  liver,  518 

Glissonian.  52  3 

hypertrophic,   of  liver,  521 

renal,  569 
Clapotage  in  dilatation  of  stomach,  457 
Claw  hand  in  muscular  atrophy,  645 

in  ulnar  paralysis,  633 
Clergyman's  sore  throat,  438 
Climatic  bubo,  97 

Clinical  methods  of  examination,  711 
Cloasma  phthisicum,  204 


Cloudy  swelling,  21 
Clubbed  fingers  in  bronchiectasis,  394 
in  mediastinal  disease,  379 
in  pulmonary  tuberculosis,  205 
Coagulms.  41 
Cocain  habit,  609 
Coccidia,  7,  268 
Coccygodynia,  635 
Coin-test  in  pneumothorax,  428 
Cholangitis,  suppurative,  after  typhoid 

fever,  62 
Colic,  509 

biliary,  537 

lead,  610 

mucous,  510 

renal,  577 
Colica  meconialis,  509 
Colitis,  acute  follicular,  484 

chronic,  478 

croupous,  in  pneumonia,  126 

diphtheritic  or  croupous,  486 

follitular,  in  typhoid  fever,  62 

mucous  or  membranous,  510 

pseudomembranous.  486 
Colles's  law  in  syphilis,   168 
Colon,  dilatation  of.  507 
Coma,  apoplectic.  662 

diabetic,   599 

epileptic,  685 

in  acute  uremia.  561 

in  alcoholism.  605 

in  erysipelas.  153 
Coma-vigil  in  typhoid  fever.  61 
Comedo  mite,   287 
Comma  bacillus  or  spirillum,  86 
Compensation,  loss  of,  349 
Complex  tic,  682 
Compressed-air  disease,  638 
Condyloma,  syphilitic,   164 
Concretions  (see  Calculi)  biliary,  536 
Conjugate  deviation    of  eyes    in    cerebral 

hemorrhage,  663 
Conjunctivitis,  diphtheritic,  134 

in  acuto  rheumatism,  158 

in  smallpox,  262 
Constipation,  503 

in  chronic  tuberculosis,  197 

in  tubercular  peritonitis,  188 

in  typhoid  fever,  ^y 

nervous,  503 

of  infants,   504 
Constitutional  diseases,  581 
Consumption  (see  Tuberculosis),  191 
Contagion,  5,  36 
Contractures    after    cerebral    hemorrhage, 

664 
Conus  medullaris,  lesions  of,  655 
Convolution,   tumor  of  third  left  frontal, 

673 
Convulsions  in  acute  uremia,  561 

in  children,  682 

infantile,  682 
Convulsive  tic,  682 
Copremia  in  constipation,  503 


INDEX 


757 


Coprolalia,  682 

Cor  bovinum,  34^ 

Cornutin-poisoning,  615 

Corpora  quadrigemina,  tumor  in.  67J 

Corset  liver,  21 

Coryza,  acute,  s^ ' 

fetida,  382 
Cuugh  in  acute  tuberculosis.   192.  19.5 

in  cancer  of  esophagus,  443 

in  chronic  tuberculosis,   195,   198 

in  measles,   108 

in  mediastinal  disease.  379 

in  pertussis,   143 

in  pneumonia,   i  2  1 
Country  fever,  618 
Coup  de  soleil,  616 
Crab-louse,  288 
Cramps,  intestinal,  500 

muscular,  in  chronic  nephritis,  571 
in  chronic  uremia,  562 
Cranial  nerves,  diseases  ol",  623 

in  cerebrospinal  meningitis.   1 1 1 
Craniotabes  in  rickets,  593 
Creatin,  6 
Creatinin,  6 

test  for,  729 
Crepitus,  gall-stone.  538 
Cresol,  6 
Cretinism,  320 
Crises,  Dietl's.  in  floating  kidney,  553 

in  locomotor  ataxia,  648 
Crisis,  20 

in  pneumonia,   120 

in  typhoid  fever,  56 
Croup,  membranous,  141 

spasmodic,  387 
Croupous  pneumonia,  115 
Crus  cerebri,  hemorrhage  into,  663 
Cryoscopy,  741 

in  diagnosis  of  cardiac  disease,  345 
Culture-media,  745 

agar,  746 

blood  serum,  746 

bouillon,  745 

milk,  746 

nutrient  gelatin,  74s 

potato,  746 
Cultures,  how  to  make,  746 
Curschmann's  spirals,  396 
Cyanosis  in  cerebral  hemorrhage,  6(32 

in  congenital  heart  disease,  369 

in  emphysema,  410 

in  mediastinal  disease,  379 

in  mitral  incompetency,  338 

in  tricuspid  stenosis,  34S 
Cydoplegia,  625 
Cyst,  hydatid,  283 

pancreatic,  542 

retention,  of  Korte,  542 
Cysticerci,  cerebrospinal.  282 

ocular,  283 
Cysticercus  cellulosac,  282 
Cystinuria,  559 
Cystitis  in  acute  rheumatism.   158. 


Cystitis  in  typhoid  fever,  66 
Cysts  of  adrenal  bodies,  313 

of  kidney,  579 
Cytolysins,  41 
Cytozoa,  7 

Dandy  fever,  84 

Day-blindness  (see  Hemeralopia)  , 

Deafness  from  cerebrospinal  meningitis.  113 

from  scarlatina,   104 

in  mumps,   145 
Death,  sudden,  in  angina,  367 

in  aortic  incompetence,  344 
in  disease  of  thymus,  321 
in  goiter,  317 
in  leukemia,  297 
in  lymphatism,  310 
in  myocarditis,  360 
in  pericarditis,  328 
in  pulmonary  infarction,  402 
in  whooping  cough,  143 
Degeneration,  21 

albuminoid,  23 

amyloid,  23 

colloid,  24 

fatty,  22 

glycogenic,  24 

hyalin,  24 

lardaceous,  2;^ 

mucoid,  24 

parenchymatous,  2  r 

reaction  of,  643 

vitreous,  24 

waxy,  24 

Zenker's,  24 
Deglutition  pneumonia,  403 
Deiter's  "spider"  cells,  639 
Dejecta  (see  Stools) 
Delafield's  theory  of  uremia,   560 
Delirium,  acute,  677 

cordis,  364 

from  alkaline  treatment,   158 

in  aortic  incompetency,  344 

in  acute  rheumatism,   156,  158 

in  acute  uremia,  561 

in  cerebrospinal  meningitis,   1  r  2 

in  erysipelas,   153 

in  measles,   108 

in  mumps,   145 

in  pneumonia,    128 

in  pyemia,   151 

in  scarlatina,  102 

in  typhoid  fever,  J7 
Delirium  tremens,  607 

in  pneumonia,   121 
Delitescence,  31 
Dementia  paralytica,  669 
Demodex  folliculorum,  287 
Dengue,  84 

Dermacantor  Americanus,  287 
Dermonyssus  avium  et  gallinae.  28.S 
Desquamation  of  measles.  107 

of  scarlatina,  102 

of  smallpox,  260 


758 


INDEX 


Diabetes,  595 

blood-tests  of,  718 

gouty,  590 

insipidus,  602 

lipogenous,  597 

phosphatic,  559 
Diaceturia,  560 
Diarrhea,  476 

alba,  485 

chronic,  47S 

chylous,  277,  485 

colliquative,  in  amyloid  kidney,  573 
in  tuberculosis,   197 

dyspeptic,  48 1 

fatty,  in  acute  pancreatitis,  541 

in  chronic  nephritis,  568 

in  chronic  uremia,  562 

in  scurvy,  ;^oy 

in  typhoid  fever,  60,  yj 

leukemic,  297 

lienteric,  478 

mucous,  or  tubular,  510 

nervous,  508 

of  Cochin-China.  2 78 

summer,  481 
Diathesis,  arthritic,   155 

hemorrhagic,   14 

lithemic,  558 
Diazo  reaction,  734 
Dietl's  crises,  553 
Digestive  system,  diseases  of,  430 

tuberculosis  of,  206 
Dioctophyme  gigas,  278 
Diphtheria,   129 

antitoxin  treatment  of,   139 

atypical,  133 

bacillus,  in  pleurisy,  418 

laryngeal,   140 

malignant,   133 

nasal,  134 

of  auditory  meatus,  134 

of  genitalia,  134 

of  skin,   134 

varieties  of,   133 

with  measles,   loS 

with   scarlatina,   102 
Diphtheritic  enteritis,  486 
Diphtheritis,   129 
Diphtheroid,  141 
Diplegia,  congenital,  666 

facial,  62S 
Diplococci,  33 

Diplococcus  intracellularis  meningitidis,  1 1 1 
Diplopia,  625 

in  chronic  nephritis,  571 
Dipsomania,  606 
Disease,   acquired,  5 

acute,  4 

bacteria  of.   t,2 

chronic,  4 

classification  of,  4 

congenital,  5 

continuous,  4 

definition  of,  3 


Disease,  functional,  4 

general,  4 

generalization  of,  8 

hereditary,  5 

local,  4 

noncontagious,  5 

organic,  4 

recurrent,  4 

sporadic,  4 

subacute,  4 
Diseases,  protozoan,  239 

the  infectious,  47 
Disinfection  in  smallpox,  264 

of  dejecta,  727 
Distoma  crassum,  269 

conjunct um,  269 

hematobium,  269 

ova  of,  in  urine,  739 

hepaticum,  269 

heterophyes,  270 

lanceolatum,  269 

ophthalmobium.  270 

pulmonale,  or  Westermanni,  269 

sinense,  269 

spatulatum,  269 
Distomiasis,  269 
Dittrich's  plugs,  390 
Diver's  paralysis,  638 
Diverticula  of  esophagus,  445 

pulsion  and  traction,  445 
Dochmiasis,  275 
Dochmius  duodenalis,  27^ 
Dorsodynia,  586 
Double  consciousness,  684 
Drachontiasis,  277 
Dreams  in  aortic  incompetency,  343 

in  tonsilitis,  441 
Dropsy,   12 

abdominal,  549 

in  aortic  incompetenc}'.  344 

in  syphilis,  165 

of  the  pericardium,  328 
Drugs  in  the  urine,  734 
Drunkenness,  605 
Dry  catarrh,  390 

mouth,  436 
Ductless  glands,  diseases  of,  289 
Dullness  in  appendicitis,  494 
Dumb  ague.  244 
Duodenal  ulcer,  459 
Dust  and  tuberculosis,   172 
Dysentery,  249 

abscess  of  liver,  in,  252 

abscess  of  lung,  in,  233 

acute  catarrhal,  2^0 

amebic,  251 

chronic,  254 

diphtheritic,  253 

follicular,  484 

forms  of,  250 

in  scurvy,  307 

intestinal  perforation  in,  255 

treatment  of,  256 
Dyspepsia,  acid,  471 


INDEX 


759 


Dyspepsia,  acute,  447 

chronic,  450 

flatulent,  451 

in  tuberculosis,  196 

nervous,  470 
Dyspeptic  diarrhea,  481 
Dysphagia  in  myelitis,  640 

in  tubercular  laryngitis,  191 
Dyspnea,  cardiac,  treatment  of,  35c 

in  acute  ascending  paralysis,  644 

in  acute  pneumonia,  193 

in  chronic  nephritis,  568,  570 

m  chronic  tuberculosis,  196,  199 

m  emphysema,  410 

in  mediastinal  disease,  379 

in  mitral  incompetency,  5;^$ 

in  pneumonia,  120 

in  trichinosis,  2^;^ 

in  tuberculosis  of  the  larynx,   190 

in  uremia,  561 

Ear  affections  in  scarlatina,   104 
Ebstein  method  in  obesity,  604 
Eburnation  in  arthritis  deformans,  582 
Ecchymosis,  15 
Echinococcus  disease.  283 

fluid,  284 

booklets  and  scolices  in  urine,  740 

multilocularis,  284 

of  brain,  lung,  pleura,  kidne\',  2S6 

of  liver,  530 

of  spleen,  315 

polymorphous,  2S3 
Echinorhynchus  gigas.  279 
Echokinesis,  682 
Echolalia,  682 
Eclampsia,  682 
Eczema  in  chronic  nephritis,  571 

in  diabetes,  599 

in  typhoid  fever,  66 

of  the  tongue,  435 
Edema,  12 

angioneurotic,  ^o;^ 

arterial,   13 

cardiac,  treatment  of.  351 

in  acute  nephritis,  564 

in  chronic  nephritis,  568 

in  exophthalmic  goiter,  319 

in  hepatic  cirrhosis,  519 

in  trichinosis,  273 

malignant,  233 

of  brain,  661 

in  mumps,  145 
in  uremia,  561 

of  glottis,  386 

in  acute  nephritis,  565 

of  lungs,  398 

in  cerebrospinal  meningitis,   11 1 
in  leukemia,  297 
in  typhoid  fever,  63 

purpuric,  302 
Egyptian  chlorosis.  275 
Eichhorst's  corpuscles  in  pernicious  anemia, 
291 


Elastic  tissue  in  sputum,  198 

Elephantiasis  Arabum,  277 

Ellis  curve  in  pleurisy,  419 

Emboli,  fat,   17 

Embolism  and  thrombosis  of  portal   vein, 

5 14 

in  aortic  incompetency,  344 

in  malignant  endocarditis,  ;i^^ 

in  pneumonia,  125 

in  typhoid  fever,  58 

of  brain,  666 

of  spinal  cord,  637 

pulmonary,  in  high  altitudes,  22^ 

retrograde,  17 
Embryocardia,  355,  365 

in  typhoid  fever,  58 
Emerods,  505 
Emphysema,  40S 

acute  vesicular,  412 

atrophic,  412 

compensatory,  408 

hypertrophic,  409 

in  whooping-cough,    143 

interstitial,  412 

'Marge  lunged,"  409 

physical  signs  of,  410 

"small  lunged,"  409 

surgical,  412 

after  paracentesis,  425 
after  peptic  ulcer,  460 
Emprosthotonos  in  tetanus,  223 
Empyema,  420 

in  influenza,  8^ 

in  tubercular  pleurisy,  186 

micro-organisms  in,  421 

necessitatis,  422 

of  gall-bladder,  538 

of  pericardium,  325 

treatment  of,  425 
Encephalitis,  acute,  667 

suppurative,  667 
Encephalopathies,  lead,  612 
Endarteritis  in  malignant  endocarditis,  332 

obliterans  in  tuberculosis,  195 
of  brain,  658 
Endemic  disease,  5 
Endocarditis,  acute,  329 

chronic,  334 

diphtheritic,  331 

gonorrheal,  162 

in  acute  rheumatism,  157 

in  cerebrospinal  meningitis,   113 

in  influenza,  8;^ 

in  pneumonia,  125 

in  scarlatina,  104 

in  syphilis,   165 

\n  typhoid  fever,  58 

infectious,  331 

malignant,  331 

recurrent,  330 

septic,  331 

ulcerative,  331 
Endospores,  ;i;^ 
Enteralgia,  509 


760 


INDEX 


Enteric  fever  (see  Typhoid  Fever).  47 
Enteritis,  acute  catarrhal,  476 

chronic  catarrhal,  478 

diphtheritic,  486 

in  children,  481 

plegmonous,  486 

pseudomembranous  or  croupous,  486 

ulcerative,  487 
Enteroclysis  in  cholera,  89 
Enterocolitis,  484 

in  measles,  loS 
Enterodynia,  508 
Enteroptosis,  507 
Enterospasm,  509 
Entozoa,  7 

Eneuresis  in  tonsilitis,  441 
Enzymes,  34 
Eosinophils  as  phagocytes,  40 

in  splenic  leukemia,  298 
Eosinophilia  in  asthma,  396 

in  distomiasis,  269 

trichinosis,  273 
Ephemeral  fever,  224 
Epidemic,  defined,  5 

hemoglobinuria,  305 

leptomeningitis,  1 1 1 

parotitis,  144 

stomatitis,  237 
Epidermal  molds  of  scarlatina,  102 
Epididymitis,  tubercular,  211 
Epiglottis,  tuberculosis  of,  190 
Epilepsy,  684 

and  typhoid  fever.  64 

cortical,  686 

Jacksonian,  686 

posthemiplegic,  686 

procursive,  685 

symptomatic  or  partial,  686 
Epileptic  seizures  after  paracentesis,  425 
Epiphyseal  enlargement  in  rickets,  594 
Epistaxis,  384 

in  hepatic  cirrhosis.  519 

in  mumps,  145 

in  scurvy,  ;i07 

in  typhoid  fever,  62 

initial,  in  purpura,  303 

vicarious,  384 
Epithelioma  of. stomach,  464 
Epithelium  in  urine,  738 
Epizoa,  7 

Erb's  juvenile  paralysis,  646 
Ergotism,  615 
Eructations,  nervous,  472 
Eruption,  cholera,  88 

of  dengue,  85 

of  measles,  107 

of  rotheln,  109 

of  scarlet  fever,  loi 

of  smallpox,  259 

of  vericella,  267 

recurrent,  in  smallpox,  262 

typhoid  fever,  66 

typhus  fever,  79 
Eruptions  in  acute  rheumatism,  158 


Eruptions  in  cerebrospinal  meningitis.  112 

in  diptheria,  136 

in  septicemia,   148 

in  trichinosis,  273 
Erysipelas,   151 

intestinal,   153 

migrans,  153 

of  mucous  membranes,  153 

pulmonary,   153 

streptococcus  of,  151 
Erythema   in  typhoid  fever,  66 
Erythrocytes,  enumeration  of,  711 

in  pernicious  anemia,  291 
Erythromelalgia,  703 
Esophagitis,  acute,  441 

chronic,  442 
Esophagus,  anesthesia  of,  444 

cancer  of,  443 

dilatation  of,  445 

diseases  of,  441 

diverticula  of,  445 

foreign  bodies  in,  445 

hemorrhage  of,  445 

hyperesthesia  of,  444 

neuroses  of,  444 

paralysis  of,  444 

rupture  of,  445 

stenosis  of,  442 

stricture  of,  442 

after  typhoid  fever,  60 

tuberculosis  of,  206 

ulcer  of,  442 

varix  of,  445 
Estivo-autumnal  fever,  243 
Etat  mamelonne  of  stomach,  451 
Ethyldiacetic  acid  in  urine,  560 
Etiology,  5 

Eustacian  tube,   involvement   of,  in    diph- 
theria, 134 
Eustrongylus  gigas,  278 
Exanthematic  typhus  (see Typhoid  Fever), 

47 
Exophthalmic  goiter,  317 
Expectoration  (see  Sputum) 
Extravasation,  10 
Exudate,  serous,  in  pleuris}',  418 
Exudative  nephritis  in  scarlatina,  103 
Eye  affections  in  typhoid  fever,  61; 

Facial  diplegia,  628 
Facial  hemiatrophy,  704 
nerve,  diseases  of,  627 
paralysis,  627 

in  diphtheria,  135 
in  mumps,  145 
Facies,  Hippocratic,  in  peritonitis,  545 
of  the  toper,  607 
of  tuberculosis,  197 
of  typhoid  fever,  55 
of  yellow  fever,  91 
Falling  sickness,  684 
False  diphtheria,  130,  141 

membrane  in  diphtheria,  130 
in  measles,  108 


INDEX 


761 


False  membrane  in  scarlatina.   102 
Famine  fever,  80 
Farcy,  229 

buds,  230 
Fasciola  hepaticum.  269 
Fastigiuni  of  fever,  20 
Fatemboli,   17 

of  lung  in  diabetes.  599 

in  urine,   "jT)"] 

-necrosis,  28 

in  acute  pancreatitis,  540 
in  dilatation  of  stomach,  457 
in  pancreatic  disease,  541 
Fatty-acid  intoxication.  6 

-acids  in  the  urine,  560 

degeneration,  22 

liver,  526 

in  tuberculosis,   195 

stools  in  chronic  pancreatitis,  541 
in  pancreatic  calculi,  543 
Fauces,  tuberculosis  of,   190 
Febricula,  224 

P>cal  impaction  in  t}'phoid  ft-ver.  60 
Feces,  examination  of,  724 
Fehleisen's  streptococcus,  151 

zones  in  erysipelas,   152 
Fehling's  test  for  sugar,  731 
Ferment,  glycogenic,  in  diabetes.  595 
Fermentation,  34 

fever,  147 
Ferments,  chemical,  34 

forms  of,  35 

in  urine,  tests  for.  729 
Fever,  19 

aseptic,  7 

in  acute  uremia,  561 

in  appendicitis,  493 

in  hepatic  abscess,  525 

in  syphilis,   164 

in  trichinosis,  273 

in  tubercular  adenitis.   183,   184 

of  pneumonia,   119 

reactionary,  91 

simple  continued,  224 
Fibrin,  test  for,  731 
Fibrinous  bronchitis,  391 

pneumonia,   115 
Fibroblasts,  31 
Fibroid  phthisis,  204 
Fibroma  moluscum.  623 
Fibrosis,  arteriocapillary.  37  • 
Fifth  nerve,  diseases  of,  626 
Filaria  Bancrofti,  276 

bronchialis,  278 

hominis  oris,  27S 

labialis,  278 

lentis,  278 

loa,  276,  278 

perstans,  276 

sanguinis  hominis,  diurna  et  nocturna, 
276 
in  urine,  739 
Filariasis,  276 
Fingers,  clubbed,  in  tuberculosis,   197 


Fish    and  shellfish-poisoning,  614 
Fistula,   gastrocutaneous,  in   peptic   ulcer^ 
460 

in  ano,  tubercular.  206 
Fits,  epileptic,  684 
Flagella,  staining  of,  744 
Fleas  and  the  plague,  94 

as  hosts  of  tenia,  280 

as  parasites,  288 
Flies  and  the  plague,  94 

and  tuberculosis,  172 

as  carriers  of  germs.  2>7 
Flint  murmur,  345 
Floating  spleen,  313 
Florida  fever,  618 
Fluctuation  in  ascites,  550 
Fluid  of  pancreatic  cyst,  542 
Flukes,  269 
Flux,  bloody,  249 
Food,  infection  by,  in  typhoid  fever,  48 

-poisoning,     614 
Foot  and  mouth  disease,  zt^j 
Foreign  bodies,  calcareous  incrustation  of, 

25 

in  esophagus,  445 
in  stomach,  468 
Formic  acid  in  urine,  560 
Formication  in  locomotor  ataxia,  648 
"  Fourth  disease,"  1 10 

nerve,  diseases  of,  626 
Fractures,  green-stick,  in  rickets,  594 
Frank  pneumonia,   123 
Friction  redux,  in  pleurisy,  420 
Friedlander's  bacillus.   116 

in  pleurisy,  41 8 
Friedreich's  ataxia.  652 
Fumigation  treatment  of  syphilis,   168 
Funnel-chest  in  tuberculosis,  441 
Furunculosis  in  cholera,  88 

in  diabetes,  599 

in  jaundice,  531 

in  scarlatina,  104 

in  typhoid  fever,  67 

Gabbet's  blue,  744 
Gait,  ataxic,  649 
Galactotoxismus,  614 
Gall-bladder,  calcification  of,  26,  53S 

cancer  of,  539 

diseases  of,  530 

dropsy  of,  538 

empyema  of,  53S 

perforation  of,  by  typhoid  bacilli,  62 
Gallop  rhythm,  364 
Galloping  consumption.   192 
Gall-stones,  536 

after  typhoid  fever,  62 

physical  properties  of,  536 

remote  effects  of,  538 
Ganglia,  basal,  tumors  of,  673 
Gangrene,  28 

after  scarlet  fever,   104 

forms  of,  2^ 

in  cerebrospin,il  meningitis,   112 


762 


INDEX 


Gangrene  in  cholera,  88 

in  typhoid  fever,  59 

of  the  lung,  414 
in  noma,  433 
Gas  in  the  urine,  560 
Gastralgia  or  gastrodynia.  474 

in  peptic  ulcer,  461 
Gastrectasia  or  gastrectasis,  455 
Gastric    contents,     microscopic     examina- 
tion of,   723 

fever,  448 

ulcer,  459 
Gastritis,  acute,  447 

after  typhoid  fever,  60 

chronic,  450 

croupous,  in  pneumonia,   126 

infectious,  448 

interstitial  or  sclerotic,  45  i 

membranous,  449 

mycotic  or  parasitic,  450 

phlegmonous  or  suppurative.  44S 

polyposa,  451 

toxic,  449 
Gastroenteritis,  481 

Gastrointestinal   catarrh  in  hepatic  cirrho- 
sis, 519 

symptoms  in  chronic  nephritis,  568,  570 
in  diabetes,   598 
in  lead  poisoning,  611 
in  uremia,  561,  562 
Gastrorrhagia,  468 
Genitourinar\-  tuberculosis,  2o3 
Geographical  tongue,  435 
German  measles,   log 
Giant-cells  in  tubercle,   jj^ 
Gibraltar  fever,  97 
Gigantorhynchus,  279 
Gilles  de  la  Tourette's  disease,  682 
Gin  drinker's  liver,  517 
Girdle  pains  in  locomotor  ataxia,  64S 

in  myelitis,  640 
Glanders.  229 
Glandular  fever,  226 
Glaucoma  in  smallpox.  262 
Glenard's  disease,  507 
Globulin  in  the  urine.  558 

test  for,  731 
Globus  hystericus,  444,  694 
Glomerulonephritis   in   scarlatina,    103 
Glossitis,  acute  and  chronic,  434 

desiccans,  435 
Glossolabiolaryngeal  paralysis,  646 
Glossopharyngeal  nerve,  disease  of,  629 
Glycogen  in  urine,  599 
Glycosuria,  alimentary,  596 

in  exophthalmic  goiter,  319 

in  calculi  of  the  pancreas,  543 

in  pancreatitis,  541 

transitory,   596 
Goiter,  316 

exophthalmic,  317 
Gonococcus  in  urine,  740 
Gonorrheal  infection,   160 
forms  of,   161 


Gout,   587 

acute,  590 

chronic,  591 

irregular,  591 

retrocedent,  591 

saturnine,  612 

sodium-biurate  deposits  in,  589 

theories  of,  588 

tophi  or  chalk-stones  in,  590 

uric-acid  showers  in,  591 
Goutiness,  591 
Grain-poisoning,  615 
Gram's  iodin  solution,  743 
Grand  or  haut  mal,   685 
Gravel,  576 
Graves's  disease,  317 
Gray  hepatization,   117 
Green  cancer,  299 

-sickness,  292 
Gregarmidse,  268 
Grip,  the,  82 
Guanin,  6 
Guinea-worm,  277 
Gumma,  syphilitic,   164 
of  spleen,  315 

Habit-chorea,  682 

from  tonsilitis,  441 
Habit-spasm  of  the  face,  628 
Haffkine's  serum,  97 
Hames's  test  for  sugar,  y^2 
Hair-tumor  of  stomach,  468 
Hallucinations  in  alcoholism,  607 
Hammerschlag's     method    of    estimating 

specific  gravity  of  the  blood,  717 
Hammond's  disease,  682 
Hanot's  disease,  521 
Hansen's  bacillus,  220 
Haptophore  groups  of  cells,  41 
Harvest-bug  as  parasite,  287 
Haut  mal,  684 
Hay  asthma,  ^8^ 

fever,  383 
Headache  in  acute  uremia,  561 

in  chronic  nephritis,  570 

in  typhoid  fever,  6^ 
Head-tetanus,  224 
Heatstroke,  616 
Heart-action  in  pneumonia,  121 

acute  dilatation  of,  355 

aneurism  of,  361 

changes  in  emphysema,  410 

congenital  defects  of.  369 

cysticercus  of,  283 

degenerations  of,  361 

dilatation  of,  in  alcoholism,  607 

diseases  of,  329 

-failure  in  diphtheria,  135 

foreign  bodies  in,  ;i62 

hurry,  365 

hypertrophy  of.  351 

and    dilatation    of,    in    tubercular 

pericarditis,   187 
in  chronic  nephritis,  568,  571 


INDEX 


763 


Heart,  hypertrophy  of,  in  gout,  590 
lesions  in  acute  rheumatism,   156 
in  cerebrospinal  meningitis,    1 1 1 
in  diphtheria,   131,   132 
in  scarlatina,   104 
neuralgia  of,  366 
neuroses  of,  363 
new  growths  of,  ^62 
palpitation  of,  363 
parasites  of,  362 
rapid  (see  Tachycardia),  365 
rupture  of,  362 
slow  (see  Bradycardia).  366 
valvular  disease  of,  334.  335 
wounds  of,  362 
Heartburn,  452,  473 
Heat-exhaustion,  616 
Heberden's  nodosities,  583 
theories  of  angina,  367 
Hebetude  in  typhoid  fever,  63 
Hectic  fever  in  pneumonic  tuberculosis,  193 
Heller's  test  for  albumin,  730 

for  hemoglobin,  731 
Hematemesis,  468 
feigned,  469 

in  hepatic  cirrhosis,   519 
in  peptic  ulcer,  461 
vicarious.  469 
Hematobia  Bilharzia,  269 
Hematochyluria,  277 
Hematoma,   15 

calcification  of,  26 
Hematoporphyrinuria,  558 
Hematozoa  of  malaria,  239 
Hematozoon  of  spotted  fever,  228 
Hematuria,  557 
endemic,  557 

in  cerebrospinal  meningitis,   112 
in  typhoid  fever,  65 
malarial,  246 
Hemeralopia  in  disease  of  optic  nerve,  625 
in  jaundice,  531 
in  scurvy,  307 
Hemianopia,  625 
Hemicrania,  689 
Hemiglossitis,  435 
Hemiplegia,   104 

after  typhoid  fever,  64 
in  mumps,   145 
in  pneumonia,   125 
in  whooping-cough,   143 
Hemoglobin,  estimation  of,  714 
Hemoglobinemia,  blood-test  for,  718 
Hemiglobinuria,  557 
epidemic,  305,  557 
in  malaria,  246 
paroxysmal,  557 
toxic,  557 
Hemolysins,  41 
Hemopericardium,  329 
Hemophilia,  304 
Hemoptysis,   199,  399 
filarial,  277 
in  tuberculosis,  196 


Hemoptysis  in  typhoid  fever,  63 
of  parasitic  origin,  400 
recurrent,  400 
treatment  of,  219 
vicarious,  400 
Hemorrhage,   14 
cerebral,  661 

in  acute  yellow  atrophy,  516 
in  cancer  of  stomach,  465 
in  diphtheria,   135 
in  icterus  neonatorum,  5;^2 
in  peptic  ulcer,  461 
in  septicemia,  148 
in  whooping-cough,  143 
internal,   15 

intestinal,  in  typhoid  fever,  61,  ^j 
into  angular  gyrus,  663 
into  cerebellum,  664 
into  crus  cerebri.  663 
into  fusiform  lobule,  663 
into  lateral  ventricles,  663 
into  liver,  514 
into  medulla,  664 
into  occipital  lobe,  663 
into  pons,  663 
into  spinal  cord,  638 
into  temporal  convolutions,  663 
intracranial,  661 
of  esophagus,  445 
of  intestine,  48S 
of  lungs,  399 
of  mesentery,  511 
of  pancreas,  539 
of  stomach,  468 
Hemorrhages  in  hepatic  cirrhosis,  519 
in  hypertrophic  cirrhosis,  522 
in  pernicious  anemia,  291 
in  scurvy,  307 
of  yellow  fever,  92 
Hemorrhagic  diathesis,  14 
diseases  of  new-born,  305 
infarct  of  lung,  401 
Hemorrhoids,  505 

in  hepatic  cirrhosis,  519 
Henoch's  disease,  302 
Hepatalgia,  515 

Hepatic   artery  and  vein,  diseases  of,  515 
fever,  534 
intermittent  fever,  533 

due  to  ball-valve  calculus,  538 
Hepatitis,  acute  parenchymatous,  515 
fibrinous,  517 
in  syphilis,   164 
interstitial,  517 
suppurative.  524 
Hepatization  of  lung  in  pneumonia,  117 
Hereditary  syphilis,  treatment  of,   168 
Heredity  in  rheumatism,   155 
Hernia,  duodenojejunal,  498 
in  whooping-cough,  144 
intra-abdominal,  498 
omental,  498 
Herpes  in  acute  tuberculosis,   179 
in  cerebrospinal  meningitis,  112 


764 


INDEX 


Herpes  in  gastritis,  448 
in  jaundice,  531 
in  typhoid  fever,  66 
zoster,  692 
Herudo  Ceylonica,  270 

vorax,  270 
Hiccough,  632 

in  choleHthiasis.  537 

in  enteralgia,  510 

in  intestinal  obstruction,  500 

in  peritonitis,  545 
Hippocratic    facies    after    perforation     of 
peptic  ulcer,  461 

in  peritonitis,  545 

in  tubercular  peritonitis,   188 

fingers,  197 
Hirschsprung's  disease,  507 
Hirudinea,  270 
Hobnail  liver,  517 
Hodgkins's  disease,  299 
Homogentisinic  acid  in  urine,  560 
Hooklets  of  echinococcus,  284 
Hospital  fever.  78 
Hour-glass  contraction  of  stomach.  449 

in  peptic  ulcer,  460 
Huntington's  chorea,  682 
Hutchinson  teeth,  166 
Hydatid  C3'st  (see  Echinococcus).  283 
Hydatid  purring,  285 
Hydremia,  9 
Hydrencephaloid,  483 
Hydrocephalic  cry,  112 
Hydrocephalus,   179,  675 

chronic,    in   cerebrospinal   meningitis, 
III,   113 

pathology  of,  12 
Hydronephrosis,  575 

intermittent.  576 
Hydropericardium,  32S 

pathology  of,  12 
Hydroperitoneum,  549 
Hydrophobia,  230 

preventive  inoculation,  232 
Hydropneumothorax,  427 
Hydrops  articulorum  intermittens,  707 

vesica;  felleae,  538 
Hydrorrhachis,  655 
Hydrotherapy,  Brand  method  of.  74 

Ziemmsen  method  of,  75 
Hydrothorax,  12,  426 
Hymenolepsis  diminuta,  280 

nana,  280 
Hyperacusis,  629 
Hyperchlorhydria,  471 
Hyperemia,  active,  1 1 

collateral,  12 

local.  1 1 

of  brain,  66  r 

of  kidneys,  554 

of  liver,  513 

of  spinal  cord,  637 

passive,  12 
Hyperesthesia,  gastric,  474 

of  esophagus,  444 


Hyperglycemia  in  diabetes,  596 

Hyperkinesis,  473 

Hyperleucocytosis  (see  Leucocytosis),  9 

Hyperorexia,  475 

Hyperosmia,  384.  624 

Hyperpyrexia.   19 

in  erysipelas,   i  53 

in  malaria.  246 

in  pneumonia.   120 

in  rheumatism,   157 

in  typhoid  fever,  56 
Hyperthyria  in  goiter,  31S 
Hypertrophic  cirrhosis,  521 
Hypertrophy  of  the  heart,  351 
concentric.  346,  352 
eccentric,  351 
Hypochlorhydria.  471 
Hypoglossal  nerve,  diseases  of,  632 
Hypoleucocj'tosis,   10 
Hypoplasia,  21 
Hypostatic  congestion,   10 
of  lung.  398 
in  typhoid  fever,  63 
Hypotonia  in  locomotor  ataxia,  649 
Hypoxanthin,  6 
Hysteria,  693 

major   and  minor,  694 

traumatic,  700 

Ichthyosis  lingua%  435 
Irhth\  otoxismus.  614 
Icterus  (see  Jaundice) 

gravis,  515 

in  hypertrophic  cirrhosis,  522 

neonatorum,  532 

physiological,  of  new-born,  532 
Idiocy,  amaurotic  family,  652 
IleocoHtis,  476 
Ileus,  498 
Imbecility    after   cerebrospinal   meningitis, 

113 
Immunity,  42 

artificial,  42 

complete  and  partial.  42 

Ehrhch's  theory  of,  43 

from  scarlatina,  loi 

from  yellow  fever,  90 

mechanism  of,  42 

natural  and  acquired,  42 
Incoordination   in  locomotor  ataxia,  649 
Indican,  test  for,  734 
Indicanuria,  559 

in  empyema,  421 

in  gastritis,  44S 
Indol,  6 

a  bacterial  jjroduct.  36 
Inebriety,  605 
Infantile  paralysis,  666 

spinal,  642 
Infantilism,  syphilitic,   166 
Infarct,  bilirubin,  calcium,  hematoidin,    19 

changes  in  the  hemorrhagic.  18 

hemorrhagic,  in  yellow  fever,  90 

melanin;  sodium-urate,   19 


INDEX 


765 


Infarct,  uric  acid.  19 
in  gout,  590 
Infarction,  18 

hemorrhagic,  of  intestine,  488 

in  scurvy,  307 
Infection,  n 

antagonism  of,  39 

cellulohumoral  theory  of,  40 

Chauveau's  theory  of,  43 

chemical  theory  of.  40 

cryptogenic.  38 

double,  in  typhoid  fever,  50 

Ehrlich's  theory  of,  40 

lymph  glands  in,  43 

Metchnikoff's  theory  of,  40 

mixed,  in  tuberculosis,   177 
in  typhoid  fever,  50 

splenic  enlargement  in,  41 
Infections  associated  with  typhoid  fever,  68 
Infectious  diseases  common  to  man    and 
lower  animals,  229 

of  doubtful  nature,  224 
Infiltration,  calcareous,  25 

dropsical,  25 
Inflammation,  29 

chronic,  31 

diphtheritic,  31 

fibrinous,  30 

hemorrhagic,  30 

necrotic,  31 

of  brain,  667 

ptirulent,  30 

secondary,  in  tuberculosis,  177 

serous,  suppurative,  30 
Influenza,  ^2 

bacillus  of,  82 

in  pneumonia,   1 16 

catarrhal  or  epidemic,  82 
Infusoria,  268 
Inhalation  pneumonia,  403 
Insanity  after  mumps,   145 

after  typhoid  fever,  64 

in   aortic  incompetency,  344 
Insects  as  means  of  infection,  ^^'j 

in  etiology  of  plague,  94 

in  typhoid  fever,   172 
of  yellow  fever,  90 
Insolation,  616 

Insomnia  from  alkaline  treatment,   158 
Intermittency  of  heart,  364 
Intermittent  fever,  239 
quartan,  243 
tertian,  242 
Interstitial  pneumonia,  406 
Intestinal  discharges,  examination  of,  724 

hemorrhagein  typhoid  fever,  6r,  yj 

obstruction,  498 

acute  and  chronic,  500 
by  abnormal  contents,  499 
by  worms,  271 
diagnosis  of,  500 

perforation,  in  typhoid  fever,  61.  yj 

poisoning,   147 

sand,  511 


Intestine,  amyloid  disease  of,  489 

diseases  of  the,  476 

hemorrhage  of,  488 

hemorrhagic   infarction  of,  488 

lesions  of,  in  typhoid  fever,  50 

neuralgia  of,  509 

neuroses  of,  508 

stricture  and  tumors  of,  499 

tuberculosis  of,  206 

knots  and  twists  of,  499 

vicarious  hemorrhage  of,  488 
Intoxication,  acid,  6 
Intoxications,  605 
Intubation  in  diphtheria,   141 
Intussusception,  intestinal,  498 
Inunction  treatment  of  syphilis.   168 
Invagination  of  bowel,  498 
Invasion,  stage  of,  20 
lodin,  test  for,  735 
Iridoplegia,  625 
Iritis  in  acute  rheumatism,  158 

scarlatinal,  104 

in  smallpox,  262 

in  syphilis,   164 
Ischemia,   1 1 

Islands  of  Langerhans  in  diabetes,  597 
Island  of  Reil,  tumor  of,  673 
Itch  mite,  287 
Ixodes,  287 

albipictus;    bovis;    ricinis,  287 

Jaeger's  bacillus,  225 
Jail  fever,  78 
Jaundice,  530 

acute  febrile,  225 

in  acute  pancreatitis,  541 

in  cancer  of  liver,  529 

in  cholelithiasis,  537 

in  hepatic  cirrhosis,  519,  520 

in  pneumonia,  126 

in  typhoid  fever,  62 

malignant,  515 

obstructive,  530 

toxemic,  532 
Jigger  as  a  parasite,  288 
Joint  lesions  in  acute  rheumatism,  156 
in  cerebrospinal  meningitis,  r  n 
in  gout,  589 
in  scarlatina,  104 
in  typhoid  fever,  67 
Jumpers,  682 

Kakki,  98 

Kidney,  amyloid,  572 

in  tuberculosis,  195 

anomalies  of  form  and  position,  552 
of  secretion,  555 

cystic,  579 

diseases  of,  552 

fatty  degeneration  of,  567 

floating,  553 

gouty,  569 

granular,  569 

hyperemia  of,  554 


766 


INDEX 


Kidney  lesions  in  cerebrospinal  meningitis, 
III 

in  malaria,  242,  245 
in  scarlatina,  103 
in  smallpox,  258 
in  typhoid  fever,  50 
movable,  552,  553 
palpable,  553 
sclerosis  of,  569 
stone  in  the,  576 
surgical,  573 
syphilis  of  the,  165 
tuberculosis  of  the,  209 
tumors  of,  579 
waxy  or  lardaceous,  572 
Kitasato's  bacillus,  94 
Klebs-Loffler  bacillus,  129 

in  membranous  gastritis.  449 
Knife-grinder's  phthisis,  407 
Koch-Ehrlich  fuchsin  solution,  743 
Kophk's  bacillus  of  pertussis,  142 

spots  in  measles,  107 
Kreotoxismus,  614 
Kuhne's  methylene  blue,  743 

Lactic-acid  intoxication,  6 

Laennec,  metallic  tinkle  of,  428 

La  grippe,  82 

Landry's  paralysis,  644 

La  perleche,  434 

Laryngeal  catarrh  in  measles,  108 

diphtheria,  133 
Laryngismus  stridulus,  386 
in  rickets,  594 
of  thymus  origin,  321 
Laryngitis,  acute  and  chronic,  385 

edematous,  386 

in  chronic  tuberculosis,  196 

in  smallpox,  262 

spasmodic,  386 

tubercular,  190 
Larynx,  ascaris  in,  271 

diseases  of,  385 

lesions  of,  in  typhoid  fever.  62 

neuroses  of,  386 

spasm  of,  386 

stenosis  of,  tubercular,  190 

tuberculosis  of,  190 
Latah,  682 
Lateral  sclerosis,  651 
Lateropulsion  in  paralysis  agitans,  679 
Lathyrism,  615 
Laveran's  plasmodium,  239 
Lead  palsy,  611 

-poisoning,  610 

test  for,  735 
Leeches  as  parasites,  270 
Leontiasis  of  leprosy,  222 

ossea,  707 
Lepra,  220 

alba,  222 
Leprosy,  220 

anesthetic,  222 
Leptomeningitis,  cerebral,  657 


Leptomeningitis,  epidemic,  1 1 1 

spinal,  636 
Leptothrix  pulmonum,  421 
Leptus  autumnalis,  287 
Leucin  in  urine,  yT^y 
Leucocytes,  enumeration  of,  714 

in  inflammation,  29 

in  pernicious  anemia,  291 
Leucocythemia,  295 
Leucocytosis,  9 

absence  of,  in  tubercular  peritonitis,  18& 
in  typhoid  fever,  57 

in  acute  meningeal  tuberculosis,  181 

in  appendicitis,  494 

in  cerebrospinal  meningitis,  1x3 

in  chlorosis,  293 

in  convalescence  of  typhoid  fever,  57 

in  diphtheria,  132 

in  distomiasis,  269 

in  empyema,  421 

in  pneumonia,   122 

in  septicemia,  148 

in  smallpox,  258 

in  trichinosis,  273 
Leucoderma  in  Addison's  disease,  312 

in  exophthalmic  goiter,  319 
Leucomaines,  6,  35 
Leukemia,  295 

lymphatic,  298 

splenomyelogenous     or      splenomedul- 
lary,  297 
Leukoplakia  buccalis,  435 
Lice,  287 

Lightning  pains  in  locomotor  ataxia,  648 
Lineae  albicantes  after  ascites,  550 
Lingual  corns,  435 

psoriasis,  435 

tonsils,  enlargement  of,  441 
Linguatilina,  287 
Linguatula  rhinaria,  287 

serrata,  287 
Lip,  tuberculosis  of,  206 
Lipaciduria,  560 
Lipuria,  560 

in  chronic  pancreatitis,  541 
Lithuria,  558 
Liver,  abscess  of,  524 

acute  yellow  atrophy  of,  515 

amyloid  disease  of,  527 
in  tuberculosis,  195 

anemia  of,  513 

angioma  of,  530 

anomalies  of  form  and  position,  512 

cirrhosis  of,  517 
capsular,  522 
hypertrophic,  521 
portal  obstruction  in,  519 
syphilitic,  164 

cancer  of,  528 

with  cirrhosis  of,  5 28 

chronic  congestion  of,  513 

diseases  of  the,  512 

of  blood-vessels  of,  514 

disturbances  of  circulation  of,  513 


INDEX 


767 


Liver,  echinococcus  or  hydatid  of,  285,  530 

fatty,   526 

flukes,  269 

large  solitary  tubercle  of,  208 

lesions  of,    in  cerebrospinal  meningitis, 
III 

in  diphtheria,  131 

in  syphilis,   164 

in  typhoid  fever,  50,  62 

in  valvular  heart  disease,  ;i3t) 

malarial,  242,  245 

malformations  and  malpositions  of,  512 

massive  cancer  of,  528 

nodular  cancer  of,  52S 

parasites  of,  530 

pyemic  abscess  of,  525 

sclerosis  of,  517 

solitary  or  tropical  abscess  of,  524 

tuberculosis  of,  208 

tumors  of,  529 
Lobar  pneumonia,   115 
Lobular  pneumonia,  402 
Lockjaw,  22;^ 
Locomotor  ataxia.  647 

ataxic  stage  of,  649 

paralytic  stage  of,  650 

preataxic  stage  of,  648 
Loffler's  methylene-blue  solution.  743 
Long  thoracic  nerve,  disease  of,  633 
Ludwig's  angina,  434 
Lues  venerea,  162 
Lumbago,  587 
Lumbar  plexus,  disease  of,  634 

puncture  in   cerebrospinal    meningitis, 
112 
Lumbricoid  worms,  270 

and  intestinal  perforation,  61,  270 

abscess  of,  413 

chronic  fibrosis  (sclerosis)  of,  406 

diseases  of,  397 

echinococcus  of,  286 

edema  of,  398 

gangrene  of,  414 

hemorrhagic  infarction  of,  401 

hyperemia  of,  397 

hypostatic  congestion  of,  398 

lesions  of,  in  diphtheria,   131 

neoplasms  of,  415 

parasitic  disease  of,  416 

sclerosis  of,  406 

splenization  of,  398 

tuberculosis  of,   192,   194 
Lung  fever,  115 
Lupinosis,  615 
Lustgarten's  bacillus,  162 
Lymph-glands  as  filters,  43 

condition  of,  in  leukemia,  296 

scrotum,  277 
Lymphadenitis,  278 

tubercular,  182 
Lymphatic  leukemia,  298 
Lymphatism,  310 

Lymphocytes  in   lymphatic  leukemia,  298 
Lymphosarcoma  of  stomach,  468 


Lj'sis,  20 

Lysophobia,  231 

McBurney's  point,  494 

Macroglossia,  435 

Maidismus,  615 

Main  en  griffe  in  ulnar  paralysis,  633 

Malacia,  475 

Malaria,  239 

clinical  forms  of,  242 

chronic,  243 

influence  of  heat  and  light  upon,  241 

latent,  247 

pernicious,  242 

stages  of,  245 
Malignant  edema,  233 

endocarditis,  331 

in  pneumonia,  125 
in  pyemia,  150 
in  scarlatina,  104 
septic  type  of,  332 
typhoid  type  of,  333 

lymphoma,  299 

pustule,  2^3 

scarlatina,  102 
Mallein,  230 
Malnutrition,  21 
Malta  fever,  97 

Mammary  gland,  tuberculosis  of,  211 
Mania,  acute,  677 

a  potu,  607 

after  typhoid  fever,  y^ 

in  mumps,  145 

in  scarlatina,  104 
Marasmus  in  cerebrospinal  meningitis,  1x3 
Marmorek's  serum,  149 
Marriage  of  consumptive,  214 

of  syphilitic,  167 
Massive  pneumonia,  123 
Measles,  106 

atypical,  108 

German,  109 

hemorrhagic  or  black,  108 

malignant,  108 
Meat-measles  of  beef  and  pork,  281" 

poisoning,  614 
Median  nerve,  paralysis  of,  634 
Mediastinitis,  378 
Mediastinopericarditis,  328 
Mediastinum,  diseases  of,  378 

tumors  of,  380 
Mediterranean  fever,  97 
Megaloblasts  in  pernicious  anemia,    291 
Megastria,  455 
Megrim,  689 
Melanin  in   urine,  y^y 
Melanogen  in  urine,  559 
Melanuria,  559 
Membranous  croup,  141 
Meniere's  disease,  629 
Meningitis,   iii,  179,  635,  656 

basilar,  179,  658 

cerebrospinal,  1 1 1 

in  erysipelas,  152 

in  pneumonia,  125 


768 


INDEX 


Meningitis  in  scarlatina,   104 
in  syphilis,   165 
in  t3'phoid  fever,  6^ 
Meninges,  cerebral,  diseases  of,  656 

lesions  of,  in  cerebrospinal  meningitis. 

in 
spinal,  diseases  of,  635 
Meningocele,  655 
Meningoencephalitis,  669 
Meningom}-elitis  in  typhoid  fever,  64 
Mercury,  test  for,  735 
Merycismus,  473 
Mesentery,  diseases  of.    511 
Metabolism,  defective,  21 

disturbances  of.  7 
Metachromatic  bodies  of  Babes,  ^2 
Metaplasia,  32 
Metasj'philitic  affections,   165 
Metchnikoff  theory,  40 
Meteorism  in  typhoid  fever,  60 
Methemoglobin  in  urine,  557 
Micrococci  in  urine,  740 
Micrococcus  lanceolatus,  115 

in  bronchopneumonia,  402 
melitensis.  97 
of  rheumatism,   155 
pneumonije,  types  of,   116 
ureae,  740 
Micromegaly,  706 

Micro-organisms  (see  Bacteria,  Bacini,etc.) 
Migraine,  689 
Migratory  pneumonia,   123 
Miliary  fever,  228 
Milk  culture-medium,  746 
-poisoning,  614 
-sickness,  237 
Millon's  albumin  test,  731 
Mind-blindness,  625 

-deafness,  675 
Miner's  lung,  407 
Miosis  in  myelitis,  640 

spinal,  in  locomotor  ataxia,  649 
Miscellaneous  diseases,  605 
Mitchell  (Weir)  method  in  obesity,  604 
Mitral  incompetency,  ^37 

stenosis,  340 
Mohr's  test  for  chlorids,  729 
Monophobia,  697 
Monostoma  lentis,  270 
Morbilli,  106 
Morbus  coxae  senilis,  583 
maculosus,  301 

neonatorum,  305 
VVerlhofi,  303 
Morning  diarrhea  in  rectal  ulcer,  487 
Morphea,  705 
Morphia  habit,  608 
Morphin,  test  for,  735 
Morphinomania,  608 
Morvan's  disease,  654 
Mosquito,  extermination  of,  248 
in  etiology  of  dengue,  84 

of  filariasis,  276 
malarial,  240 


Mosquito  of  yellow  fever,  90 
Motor  area,  tumors  of,  67 t, 
Mountain  fever,  227 
Mouth-breathing,  440 
Mouth,  care  of,   in  typhoid  fever,  74 

diseases  of  the,  430 

tuberculosis  of.  206 
Mucous  patches,   164 
Mumps,   144 
Murmurs,  cardiac,  functional,  348 

musical,  347 
Muscles,  degenerations  of,  in  typhoid  fever, 

67 

diseases  of  the,  618 
Muscular  atrophy  in  acute  rheumatism,  158 
Musculocutaneous  nerve,  disease  of,  633 
Musculospiral  nerve,  disease  of,  633 
Mushroom-poisoning,  616 
Mussel  poisoning,  615 
Myalgia,  386 
Mycosis  nitestinahs,  234 
Myelitis,  acute,  638 

central,  639 

compression,  641 

diffuse,  disseminated,  639 

general  or  transverse,  639 

syphilitic,  165 
Myelocele,  655 

Myelocytes  in  splenic  leukemia,  298 
Myocarditis,  acute,  356 

chronic,  357 

in  acute  rheumatism,   157 

in  influenza,  83 

in  smallpox,  262 

in  typhoid  fever,  51,  58 

in  typhus  fever,  78 
Myocardium,  diseases  of,  356 
Myoidema  in  tuberculosis,  202 
Myositis,  618 

infectious,  618 

ossificans  progressiva,  619 

trichinous,  273 
Myotonia  congenita,  619 
Mytilotoxismus,  615 
Myxedema,  320 

operative,  321 

Nails,  incurved,  in  bronchiectasis,  394 

in  tuberculosis,   197 
Nasopharyngeal  obstruction,  chronic,  440 
Nauheim  method  in  myocarditis,  361 
Neapolitan  fever,  97 
Necrosis,   causes  and  forms  of,  27 
Nematodes,  7 

diseases  caused  by,  270 
Nephritis,  acute,  563 

in  diphtheria,   136 

in  scarlet  fever,   103 

in  typhoid  fever,  65 

uremic  symptoms  in,  565 
acute   diffuse,    acute  parenchymatous, 

563 
chronic,  567 

diffuse  or  desquamative,  567 


INDEX 


769 


Nephritis,  chronic  interstitial,  569 
parenchymatous,  567 
tubal,  567 

uremic  symptoms  in,  571 
Nephrolithiasis,  576 
Nephroptosis,  552 
Nephrotyphoid  fever,  65 
Nerves,  diseases  of,  621 
Nervous  diarrhea,  508 
dyspepsia,  470 

system,  central,  tuberculosis  of,  205 
diseases  of,  621 
functional,  677 
in  diphtheria,  131,  132 
in  scarlatina,  104 
in  typhoid  fever,  63 
Nervus  abducens,  disease  of,  627 
Neuralgia,  690 
intercostal,  691 
intestinal,  509 
lumbar,  691 

metatarsal  and  plantar,  692 
of  pharynx,  437 
phrenic,  691 
red,  703 

tender  points  in,  691,  692 
trifacial,  691 
Neurasthenia,  696 
Neuridin,  6 
Neuritis,  621 

acute  febrile  multiple,  622 
alcoholic,  606 
arsenical,  613 
ascending,  622 
endemic,  98 
in  beriberi,  99 
in  diabetes,  599 
in  diphtheria,  131 
in  typhoid  fever,  64 
localized,  621 
migratory,  622 
multiple,  621,  622 

in  typhoid  fever,  64 
optic,  624 

in  basilar  meningitis,  658 
in  meyelitis,  640 
peripheral,  in  erysipelas,  153 
in  pneumonia,  126 
in  smallpox,  262 
progressive  interstitial  hypertrophic, 

653 
Neuromata,  623 
Neuroretinitis,  104 
Neuroses,  nasal,  384 

occupation,  699 

of  esophagus,  444 

of  gastric  motion,  472 

of  gastric  secretion,  470 

of  gastric  sensation,  474 

of  heart,  363 

of  intestine,  508 

of  larynx,  386 

of  stomach,  470 

traumatic,  700 


Neurosis,  pathology  of,  4 
Night-blindness  (see  Nyctalopia) 
Night-sweats  in  tuberculosis,  197 

treatment  of,  218 
Nodding  spasm,  631 

Nodosities,    subcutaneous,    in  acute  rheu- 
matism, 158 
Noma,  432 

in  diphtheria,  136 

in  measles,  108 

in  scarlatina,  104 

in  typhoid  fever,  59 
Nose,  diseases  of,  381 

neuroses  of,  384 

-bleed,  384 
Nutmeg  liver,  513 

atrophic,  514 
Nutrition,  disturbances  of,  7 
Nyctalopia  in  disease  of  optic  nerve,  625 

in  jaundice,  531 

in  scurvy,  307 
Nystagmus  in  cerebrospinal  meningitis,  112 

in  hereditary  ataxia,  653 

in  insular  sclerosis,  672 

Obermeier,  spirillum  of,  80 

Obesity,  603 

Obstipation,  498 

Occipital  lobe,  tumors  of,  6^;^ 

Oculomotor  nerves,  diseases  of,  625 

Oertel's  method  in  myocarditis,  361 

in  obesity,  604 
Olfactory  nerve  and  tract,  disease  of,  623 
Oligemia,  9 

Omental  bursa,  hernia  of,  498 
Omodynia,  586 
Ophthalmoplegia,  627 
Opisthotonos  in  meningitis,  112 

in  tetanus,  223 
Opium  habit,  608 
Optic  nerve,  atrophy  of,  624 

and  tract,  disease  of,  624 
Optic  neuritis,  624 
malarial,  247 
in  acute  rheumatism,  158 
in  pericarditis,  323 
Orthotonos  in  tetanus,  223 
Osteitis  deformans,  706 
Osteoarthritis,  581 

Osteoarthropathy,     hypertrophic     pulmo- 
nary, 706 
Osteoblasts,  32 
Osteosclerosis,  582 
Osteoscopic  pains,   164 
Otitis  media  in  diphtheria,  134 

in  measles,  108 

in  pneumonia,  126 

in  scarlatina,  104 

in  smallpox,  262 

in  typhoid  fever,  59 

syphilitic,  164 
Oxaluria,  559 

Oxybutyric  acid  in  urine,  560 
Oxyuris  vermicularis,  271 


77° 


INDEX 


Oyster-  and  clam-poisoning,  615 
Ozena,  382 

Pachymeningitis,  cerebral,  656 

spinal,  635 
Pains,  fulgurant,  in  locomotor  ataxia,  649 

in  aortic  aneurism,  375 

in  appendicitis,  493 

in  cancer  of  stomach,  465 

in  cholelithiasis,  537 

in  chronic  tuberculosis,  199 

in  nephrolithiasis,  577 

in  pancreatic  cyst,  542 

in  peritonitis,  544 

in  pneumonia,  120 

in  pyelitis,  574 
Painter's  colic,  611 
Palpitation,  363 

cardiac,  treatment  of,  351 
Paludism,  239 
Pancreas,  diseases  of,  539 

in  diabetes,  596 

hemorrhagic,  539 

tuberculosis  of,  208 

tumors  of,  543 
Pancreatic  calculi,  543 

cyst,  542 

duct,  obstruction  by  ascaris,  270 
Pancreatitis,   acute,  540 

chronic,  541 

gangrenous,  541 

hemorrhagic,  540 

suppurative,  540 
Pandemic,  5 
Panophthalmitis    in  exophthalmic  goiter, 

319 
Papilloma  of  stomach,  468 
Papular  syphilid,  164 
Paracentesis  in  pleurisy,  424 
Para-  infections,  71 
Paralysis,  acute,  644 

agitans,  678 

antibrachial,  611 

Aran-Duchenne,  due  to  lead,  612 

arsenical,  613 

brachial,  due  to  lead,  611 

bulbar,  646 

cerebral,  of  childhood,  666 

crossed,  spinal,  643 

diphtheritic,   135 

Erb's  juvenile,  646 

essential  or  atrophic,  642 

functional,  701 

general,  due  to  lead,  612 

glossolabiolaryngeal,  646 

in  cerebrospinal  meningitis,  113 

in  malaria,  247 

infantile,  666 

Landry's,  644 

of  esophagus,  444 

of  facial  nerve,  627 

of  larynx  due  to  lead,  612 

of  oculomotor  nerve,  625 

periodical,  701 


Paralysis,  peroneal,  612 

progressive,  of  the  insane,  669 

scapulohumeral,  611 

spastic  spinal,  651 

spinal,  642 
Paralytic  stroke,  661 
Paramyoclonus,  620 
Paraplegia,  ataxic,  652 

congenital,  666 

due  to  myelitis,  640 

hereditary  toxic,  652 

hysterical  spastic,  652 
Parasite,  estivo-autumnal,  240 

quartan,  240 

tertian,  239 
Parasites,  animal,  7 

diseases  due  to,  239 
in  urine,  739 

facultative,  32 

vegetable,  in  urine,  740 
Parasitic  disease,  5 
Paraxanthin,  6 

"  Parchment  crackling"  in  rickets,  593 
Paresis,  general,  669 
Parietal  region,  tumor  of,  673 
Parkinson's  disease,  678 
Paronychia,  syphilitic,  166 
Parorexia,  475 
Parosmia,  385,  624 
Parotid  bubo,  436 

gland,    gaseous     distention     of,     436 
lesions  of,  in  typhoid  fever,  59 
Parotitis,  chronic,  436 

epidemic,  144 

suppurative,  in  peptic  ulcer,  461 
in  typhoid  fever,  59 

symptomatic  or  secondary,  436 
Paroxysmal  disease,  4 
Parry's  disease,  317 
Pediculosis,  287 
Pediculus  capitis,  287 

corporis,  288 

vestamentorum,  288 
Peliosis  rheumatica,  302 
Pellagra,  615 

Pentastoma  tenioides,  287 
Pentastomum  constrictum,  287 

denticulatum,  287 
Pepsin,  test  for,  721 
Peptic  ulcer,  459 

gastralgia  in,  461 
hemorrhage  in,  461 
perforation  of,  461 
Pepton  in  stomach-contents,  test  for,  721 
Peptonuria,  421 

in  pernicious  anemia,  292 
Perforation  of  the  bowel,  61,  yy 

in  appendicitis,  492 
Pericarditis,  acute,  322 

adhesive,  323 

cancerous,  328 

chronic,  327 

external,  328 

gonorrheal,  162 


INDEX 


771 


Pericarditis  in  acute  rheumatism.  157 

in  erysipelas,  152 

in  influenza,  83 

in  pneumonia,  125 

in  scarlatina,  104 

purulent,  325 

tubercular,  186 

with  effusion,  323 
Pericardium,  adherent,  ;i2y 

calcification  of,  25 

empyema  of,  325 

diseases  of,  322 
Perihepatitis,  acute,  522 

chronic,  523 

in  chronic  gastritis,  451 
Perinephric  abscess,  578 
Periodic  disease,  4 
Periosteal  hemorrhage  in  infantile  scurvy, 

309 
Perisplenitis  in  chronic  gastritis,  451 
Peristalsis,  reversed,  in  dilatation  of  stom- 
ach, 457 
Peristaltic  unrest,  473 
Peritoneum,  cancer  of,  549 

diseases  of,  543 

tuberculosis  of,  187 
Peritonitis,  acute,  543 

appendicular,  546 

chronic,  548 

from  peptic  ulcer,  461 

general  adhesive,  548 

in  chronic  gastritis,  451 

in  leukemia,  297 

in  pneumonia,  126 

in  scarlatina,  104 

in  typhoid  fever,  62 

local  adhesive,  548 

localized,  546 

pelvic,  547 

primary,  543 

proliferative,  548 

secondary,  544 

subphrenic  (see  Perihepatitis) 

tubercular,  187 
localized,  i88 
Perles  of  Laennec,  396 
Pernicious  anemia,  290 
Pertussis,  142 

Pestis — major,  minor,  siderans,  95 
Petechia,  15 
Petit  mal,  686 
Pfeiffer,  bacillus  of,  82 
Pfuhl's  sign,  523 
Phagocytosis,  40 

in  malaria,  240 
Pharyngeal  diphtheria,  133 

tonsil,  enlargement  of,  440 
Pharyngitis,  acute,  437 

chronic,  438 

granular,  438 

tubercular,  190,  206 

ulcerative,  438 
Pharynx,  anemia  and  hyperemia  of,  436 

and  uvula,  edema  of,  437 


Pharynx,  diseases  of,  436 

hemorrhage  of,  437 

spasm  and  paralysis  of,  437 

tuberculosis  of,  190 

ulcers  of,  436 
Phenol,  6 

a  bacterial  product,  ^6 
Phenylhydrazintestin  chronic  pancreatitis, 

541 
Phlebitis  in  pyemia, 
Phlegmon,  acute  infectious,  438 
Phlegmonous  enteritis,  468 

phosphates  in  urine  sediment,  ;^;iy 
test  for,  729 
Phosphoric-acid  intoxication,  6 
Phosphatic  diabetes,  559 
Phosphaturia,  559 
Phrenic  nerve,  disease  of,  632 
Phthiriasis,  287 
Phthirius  pubis,  288 
Phthisical  chest,  201 

habit,  174 
Phthisiophobia,  213 
Phthisis,  chronic,  194 

fibroid,  204 

florida,  192 

pneumonic,   192 

pulmonum  (see  Tuberculosis),  191 
Pica,  475 
Pigeon-breast  in  rickets,  594 

in  tonsilitis,  441 
Pigmentation,  varieties  of,  26 

in  Addison's  disease,  312 

in  pseudoleukemia,  301 
Piles,  505 

Pine  acids,  test  for,  y^6 
Pinworm,  271 
Plague,  the,  94 

clinical  forms  of,  95 
Plasmodium  malariae,  239 

staining  of,  716 
Plate-cultures,  747 
Plethora,  9 
Pleura,  diseases  of,  417 

echinococcus  of,  286 

tuberculosis  of,  185 
Pleurisy,  acute,  417 

adhesive  or  "dry,"  425 

chronic,  425 

with  effusion,  426 

diaphragmatic,  423 

encysted,  422 

fibrinous,  417 

hemorrhagic,  422 

in  chronic  tuberculosis,  196 

in  pneumonia,  125 

interlobular,  423 

primary,  417 

pulsating,  422 

purulent,  420 

secondary,  417 

serofibrinous,  418 

Special  forms  of,  422 

treatment  of,  424 


772 


INDEX 


Pleurisy,  tubercular,  185,  422 
Pleurodynia.  586 
Pleuropericarditis,  32S 
Pleuropneumonia,  125 
Pleurothotonos  in  tetanus,  22;^ 
Plica  polonica,  287 
Plumbism,  610 
Pneumatosis,  472 
Pneumaturia,  560 

in  diabetes,  599 
Pneumococcus,  115 

in  pleurisy,  417,  418 
Pneumogastric  nerve,  diseases  of,  629 
Pneumokoniosis,  407 
Pneumonia,   115 
afebrile,  124 
after  pleurisy,  123 
after   surgical  operations,  1^1. 
alcoholic,  123 
apyretic,  124 
caseous,  176 
catarrhal,  402 
central,  123 
cerebral,  121 
chronic  interstitial,  406 
crossed,  118 
double,  118 
fibrous,  406 
epidemic,  123 
in  diphtheria,  135 
in  erysipelas,  152 
in  infants,  124 
in  influenza,  83 
in  leukemia,  297 
in  smallpox,  262 
in  the  aged,  124 
in  typhoid  fever,  62,  6,^ 
in  whooping-cough,  £43 
lobular,  402 
relapse  in,  125 
varieties  of,  123 
Pneumonitis,  115 
Pneumopericardium,  329 
Pneumothorax,  427 
Podagra,  587 
Poikilocytosis  in  chlorosis,  293 

in  pernicious  anemia,  291 
Poliomyelitis,  acute  anterior,  642 
in  adults,  644 
in  children,  642 
in  typhoid  fever,  64 
chronic,  645 
Polyarthritis,  chronica  villosa,  584 
Polycythemia,  289 

with  chronic  cyanosis,  289 
Polydipsia,  602 
Polyneuritis,  621 
Polyphagia,  475 

Pons  and  medulla,  tumors  of,  6ys 
Popoff's  micrococcus  of  rheumatism,   155 
Porencephalus,  666 
Pork  tapeworm,  279 

Porocephalus  constrictus,  287  I514 

Portal  vein,  embolism  and  thrombosis  of, 


Portal  vein,  stenosis  of,  515 
Postepileptic  state,  686 
Posthemiplegic  chorea,  682 
Post-mortem  wart,  173 
Potato  culture-medium,  746 
Pox  (see  Syphilis),  162 
Prefrontal  region,  tumor  of,  673 
Pressure  symptoms  in  aneurism,  374,  ;i28 
in  hepatic  abscess,  525 
in  mediastinal  disease,  379 
Priapism  in  enteralgia,  510 

in  leukemia,  297 
Progressive  bulbar  paralysis,  646 
muscular  atrophy,  645 
acute,  618 
facial  typ>e  of,  646 
peroneal  type  of,  646 
paralysis  of  the  insane.  669 
Propepton,  test  for,  721 
Propionic  acid  in  urine,  560 
Proptosis  in  infantile  scurvy,  309 
Propulsion  in  paralysis  agitans,  679 
Prosopalgia,  691 
Prostate,  tuberculosis  of,  210 
Prostration,  nervous,  696 
Proteids  in  gastric  contents,  test  for,  721 
Proteins,  35 
Protozoa,  7 

Protozoan  diseases,  239 
Protozoon  in  leukemia,  295 

of  smallpox,  257 
Prune-juice  expectoration,  121 

in  acute  tuberculosis,  193 
in  tumors  of  the  lung,  416 
Pruritus  in  chronic  nephritis,  571 

in  jaundice,  530 
Psamomata,  25 
Pseudoangina,  368 
Pseudocrisis  in  pneumonia,  120 
Pseudodiphtheria,  141 
Pseudohydrophobia,  231 
Pseudoleukemia,  299 

splenic,  315 
Pseudomembrane —  pultaceous,    punctate, 

133 

in  diphtheria,  130 

in  measles,  108 

in  scarlatina,  102 
Pseudotrichinosis,  274 
Psilosis,  485 
Psittacosis,  236 
Psorospermiasis,  268 
Psorosperms,  7 

in  empyema,  421 
Psychical  centers,  tumors  of,  6yi 
Psychical  state  in  tuberculosis,  201 
Ptomain-poisoning,  147,  614 
Ptomains,  6,  35 
Ptosis  in  cerebrospinal  meningitis,  ii2 

in  diphtheria,  135 
Ptyalism,  433,  435 
Pulex  irritans,  penetrans,  288 
Pulmonary  apoplex}',  401 

collapse,  412 


INDEX 


773 


Pulmonary  collapse  in  diphtheria,  135 

erysipelas,  153 

hemorrhage,  399 

valve  lesions,  348 
Pulsation,  capillary,  344 

expansile  in  aneurism,  375 
Pulse,  delayed,  in  aneurism,  :^y6 

of  acute  tuberculosis,  192,  193 

of  acute  uremia,  561 

of  aortic  incompetency,  344 

of  cerebrospinal  meningitis,  112 

of  chronic  tuberculosis,  201 

of  pneumonia,  121 

of  pyemia,  151 

of  tubercular  peritonitis,  188 

of  typhoid  fever,  58 

of  yellow  fever,  92 

paradoxical,  364 

water-hammer,  344 
Pulsus  paradoxus  in  pericarditis,  2,22,.  :i2?, 
Purpura,  301 

arthritic,  302 

fulminant,  303 

hemorrhagica,  303 

in  cerebrospinal  meningitis,  112 
in  scarlatina,  104 
in  typhoid,  66 

infectious,  302 

rheumatica,  simplex,  302 

symptomatic,  urticans,  302 
Pus,  acid,  in  pyelitis,  575 

in  urine,  738 
Putrescin,  6 
Putrid  sore  throat,  129 
Pyelitis,  573 
Pyemia,  150 

in  malignant  endocarditis,  2,7,2 
Pylephlebitis,  adhesive,  514 

due  to  peptic  ulcer,  461 

in  typhoid  fever,  62 

suppurative,  515 
Pylorus,  relaxation  of,  473 

spasm  of,  473 

stricture  of,  460 
Pyonephrosis,  573 
Pyopneumothorax,  427 

in  tubercular  pleurisy,  186 

in  typhoid  fever,  63 

subphrenic  or  subdiaphragmatic,  522 
in  peptic  ulcer,  460 
Pyrexia,  19 
Pyrosis,  473 

in  chronic  gastritis,  452 
Pyuria,  558 

in  typhoid  fever.  65 

Quartan  intermittent  fever,  243 
Quinin,  test  for,  735 

Quinsy  (see  Tonsilitis,  suppurative),  439 
Quotidian  intermittent  fever,  243 

Rabies,  230 
Rachitis,  593 
Rag-pickers'  disease,  232 


Railway  spine,  700 

R3Ie,  crepitant,  in  pneumonia,  122 

Ray  fungus,  235 

Raynaud's  disease,  701 

Rash  (see  Eruption) 

Reaction  of  degeneration,  643 

Reactionary  fever,  in  cerebral  hemorrhage, 

663, 
Receptors,  Ehrlich's  theory  ol,  40 
Recrudescence,  4 

in  typhoid  fever,  68 
Recurrent  fever,  80 
Red-corpuscles,  enumeration  of,  711 
Red  hepatization,  117 

neuralgia,  648 
Reflexes  in  locomotor  ataxia,  648 

in  multiple  neuritis,  622 
Regeneration,  normal,  pathological,  31 
Regurgitation,  gastric,  473 
Relapsing  fever,  80 
Remittent  fever,  243 

bilious,  246 
Renal  colic,  577 

.  intermittent  fever,  577 
Rennet,  test  for,  721 
Resolution,  31 

delayed,  in  pneumonia,  124 

in  pneumonia,  122 
Resorption  fever,  147 
Respiration,  cog-wheel,  202 

in  cerebral  hemorrhage,  662 

in  cerebrospinal  meningitis,  112 

in  chronic  tuberculosis,  201,  202 

in  peritonitis,  545 
Respiratory  system,  diseases  of,  381 

lesions  of  in  typhoid  fever,  62 
Retinitis  in  chronic  nephritis,  571 

syphilitic,  164 
Retrograde  processes,  20 
Retropharyngeal  abscess,  438 
Retropulsion  in  paralysis  agitans,  679 
Rhabdomyoma  of  kidney,  5,79 
Rhabdonema  intestinahs,  278 
Rheumatic  fever,  154 
Rheumatism,  acute,  154 
in  children,  157 

acute  articular,  154 

acute  inflammatory,  154 

chronic,  584 

gonorrheal,  161 

in  erysipelas,  153 

in  pneumonia,  126 

inflammatory,  154 

muscular,  586 

scarlatinal,  104 

subacute,  157 

theories  of,  155 
Rhexis,  14 
Rhinitis,  acute,  381 

atrophic,  382 

chronic  h}'pcrtrophic,  3 

fibrinous,   134 

sj'philitic,  166 

tubercular,  190 


774 


INDEX 


Rice-water  dejecta,  87 
Rickets,  593 

acute  (infantile  scurvj"^),  30S 

rosar}'  of,  594 
Riga's  disease,  434 
Rigidit}^  in  paralysis  agitans,  678 

of  rectus  in  appendicitis,  494 

post-paralj^tic,  664 
Rigors  (see  Chills) 
Risus  sardonicus,  112 
Roberts's  test  for  globulin,  731 
Romberg's  symptom,  649 
Rose  cold,  383 

-spots      in     cerebrospinal     meningitis 
112 
in  typhoid  fever,  66 
Roseola  of  syphilis,  164 
Rotheln,  109 

Round  ulcer  of  stomach,  459 
Rubella,  109 

scarlatinosa,  no 
Rubeola,  106 

notha,  109 
Rumination,  473 
Rusty  sputum  in  pneumonia,  121 

St.  Anthony's  or  St.  Vitus's  dance,  682 

Sable  intestinalis,  511 

Saccharomyces  albicans  in  thrush,  431 

Sacral  plexus,  diseases  of,  634 

Sago  spleen,  315 

Salicylic  acid,  test  for,  736 

Saline  injections  in  cholera,  89 

Saliva  of  acute  rheumatism,  156 

Salivary  glands,  diseases  of,  435 

Salpingitis,  tubercular,  211 

Sanarelli,  bacillus  of,  89 

Sand-flea,  288 

Santonin,  test  for,  736 

Sapremia,  147 

Saprin,  6 

Saprophytes,  32 

Sarcinas,  ^^^ 

in  urine,  740 

ventriculi,  in  cancer  of  stomach,  466 
in  dilatation  of  stomach,  457 
Sarcoblasts,  32 

Sarcolactic-acid  intoxication,  6 
Sarcoma  of  adrenals,  311 
"  Sarcoma  of  leucocytes,"  295 
Sarcoma  of  lung,  415 

of  spleen,  315 
Sarcoptes,  287 
Saturnism,  610 
Scapulodynia,  586 
Scarlatina,  100 

anginose  type  of,  103 

forms  of,  102 

foudroyant,  103 

hemorrhagic,   103 

malignant,  102 

miliaris,  loi 

puerperal,  103 

sine  eruptione,  102 


Scarlatina  surgical,  103 
Scarlet  fever,  100 

rash,  100 
Schlammfieber,  226 
Schonlein's  disease,  302 
Schott's  method  in  myocarditis,  361 
Sciatica,  634 
Scirrhus  of  stomach,  464 
Scleroderma,  704 
Sclerose  en  plaques,  671 
Sclerosis,  amyotrophic  lateral,  645 

disseminated,  671 

insular,  671 

multiple  cerebrospinal,  671 

of  brain,  671 

of  kidney,  569 

posterolateral,  652 

primary  lateral,  65 1 

spinal,  647 

toxic  combined,  65;^ 

ventriculi,  451 
Scolex  of  echinococcus,  284 
Scorbutus,  306 
Scotoma  in  amblyopia,  625 
Scrivener's  palsy,  699 
Scrofula  (scrofulosis),  182 
Scrofulous  frame,  174 
Scurvy,  306 

dysentery,  307 

in  infants,  308 

sclerosis,  307 
Sepsis,  146 

in  diphtheria,  136 

in  smallpox,  262 
Septicemia,  146 

true  or  progressive,  147 

typhoid,  49 

varieties  of,  147 
Septicopyemia,  150 
Serum,  antitetanic,  224 

Haffkine's,  97 

reaction  in  cholera,  88 

in  typhoid  fever  (see  Widal  test) 
in  yellow  fever,  90 

treatment  of  acute  rheumatism,  160 
of  cholera,  89 
of  diphtheria,   139 
of  plague,  97 
of  pneumonia,   127 
of  septicemia,  149 
of  typhoid  fever,  76 

Yersin-Roux,  97 
Seven-day  fever,  80 
Shaking"  pals\',  678 

Shaved  beard  appearance  of  bowel,  479 
Shiga's  bacillus,  250 

in  gastroenteritis,  48 1 
Shingles,  692 
Ship  fever,  78 

Shock,  diastolic,  in  aneurism,  375 
Sick  headache,  6S9 
Siderosis,  407 

Sinus-thrombosis,   autochthonous,  659 
Siriasis,  616 


INDEX 


775 


Sitotoxismus,  615 

Sixth  nerve,  disease  of,  627 

Skatol,    36 

Skoda's  resonance  in  pleurisy,  419 

Smallpox,  256 

malignant,  261 
protozoon  of,  257 
Smoker's  tongue,  435 
Snuffles  in  congenital  syphilis,  166 
SoUtary  ulcer  of  bowel,  487 
Solutions  for  staining  bacteria,  742 
Somnambulism,  684 
Sordes,  59 

Sore  mouth,  fetid  or  putrid,  431 
Sore  throat,  437 

Spasm,  carpopedal,  in  rickets,  594 
nodding,  631 
of  cardia,  473 
of  pylorus,  473 
professional,  699 
Spastic  paralysis,  Erb's  syphilitic,  652 
secondary,  652 
paraplegia,  hereditary,  651 
hysterical,  652 
Speech,  scanning,  in  insular  sclerosis,  672 
Spermatozoa  in  urine,  739 
Sphacelinic-acid  poisoning,  615 
Sphacelus  in  pulmonary  gangrene,  414 
Sphenoid,  chronic  disease  of,  438 
Spina  bifida,  655 

Spinal  accessory  nerve,  diseases  of,  630 
cord,   affections    of   blood-vessels    and 
circulation  of,  637 
compression  of,  641 
diseases  of,  635 
inflammation  of,  639 
malformations  of,  655 
tumors  of,  654 
white  softening  of,  639 
meninges,   diseases  of,  635 
nerves,  diseases  of,  632 
paralysis,  642 
sclerosis,  647 
Spirilla,  33 

Spirocheta  of  relapsing  fever,  80 
Spleen,  abscess  of,  314 
amyloid  disease  of,  315 
diseases  of,  313 
features  of,  in  diphtheria,  131 
in  hepatic  cirrhosis,  519 
in  leukemia,  296 
in  lymphatic  leukemia,  299 
in  malaria,  242,  245 
in  pseudoleukemia.  301 
in  smallpox,  258 
in  typhoid  fever,  50,  59 
infarction  of,  314 
movable,   313 
rupture  of,  313 
tuberculosis  of,  208 
tumors  of,  315 
Splenic  anemia,  315 

fever,   232 
Splenitis,   acute  and  chronic,  314 


Splenomegaly,  315 
Splenoptosis,  313 
Spondylitis  deformans,  583 
Sporagenous  granules  of  Ernst,  32 
Spores,   staining  of,  744 
Sporozoa,   268 
Sporulation,  33 
Spotted  fever,  78,  1 1 1 

of  Rocky  mountains,  227 
Sprue  or  psilosis,  485 
Sputum,  albuminous,  in  pleurisy,  425 

examination  of,  748 

in  acute  tuberculosis,  193 

in  chronic  tuberculosis,  198 

in  gangrene  of  the  lung,  414 

in  pneumonia,  121 

nummular,   198 

of  bronchial  asthma,  396 

of  bronchiectasis,  394 

of  fetid  bronchitis,  390 

of  pneumokoniosis,  408 
Stab-culture,  747 

Staccato  speech  in  insular  sclerosis,  672 
Staining,  bacterial,  742 

blood  specimens,  715 

malarial  plasmodia,  716 
Stains:   Plehn's,  716 

Whitney's,  716 

bacterial,  carbol-fuchsin  (Ziehl's),  143 
carbol-thionin,  743 
for  flagella,  744 
for  spores,  744 
Gabbet's  blue,  744,  748 
Gram's  iodin,  743 
Koch-Ehrlich  anilin  water  fuchsin, 

743 
Kuhne's  methylene  blue,  743 
Lofifler's  methylene  blue,  743 
Welch's  capsule  stain,  744 
basophile,  716 
of  blood  specimens  : 
Biondi's,  715 
Ehrlich's,  715 

eosin  and  methylene  blue,  715 
Staphylococci  in  pneumonia,  ri6 
Stasis,  venous,  12 
Status  epilepticus,  686 

lymphaticus,  310 
Stegomyia  fasciata,  90 
Stenocardia,  366 
Stenosis  of  esophagus,  442 
Steppage  gait,  622 
Stercoral  ulcers,  487 
Stigmatization,   14 

Stomach,  absorptive  power,  test,  724 
atony  of,  474 
atrophy  of,  450 
cancer  of,  463 
capacity  of,  445 
cirrhosis  of,  451 
-contents,   examination  of,  719 
in  chronic  gastritis,  452 
qualitative  tests  of,  720 
quantitative  tests  of,  722 


776 


INDEX 


Stomach,  dilatation  of,  455 

after  typhoid  fever,  60 

diseases  of,  445 

examination  of,  446 

foreign  bodies  in,  468 

hemorrhage  of,  468 

hour-glass  contraction  of,  449 

hypertrophic  stenosis  of,  468 

motor  power,  test,  724 

neuroses  of,  470 

nonmalignant  tumors  of,  468 

normal  secretion  of,  445 

-tube,  introduction  of,  719 

tuberculosis  of,  206 

ulcer  of,  459 

volvulus  of,  456 

washings,  examination  of,  724 
Stomatitis,  aphthous,  430 

catarrhal,  430 

diphtheritic  or  croupous,  433 

epidemic,  237 

follicular  or  vesicular,  430 

gangrenous,  432 

in  chronic  uremia,  562 

in  diabetes,  598 

in  typhoid  fever,  59 

membranous,  433 

mercurial,  433 

parasitic  or  mycotic,  431 

syphilitic,  164 

ulcerative,  431 
Stone  in  the  kidney,  576 
Stools,  disinfection  of,  727 

examination  of,  724 

in  cholera  infantum,  483 

in  cholera  morbus,  480 

in  jaundice,  531 
Strabismus  in  cerebrospinal  meningitis,ii2 

in  diphtheria,  135 
Strangulation,  intestinal,  498 
Strangury  in  enteralgia,  510 
Strapping  in  hemoptysis,  219,  401 
Streptococci,  ^^ 
Streptococcus  of  Fehleisen,  151 

diphtherias,  141 

pj'Ogenes  in  pneumonia,  116 
Streptothrix  actinomyces,  235 
Stricture  of  the  bowel,  499 

of  esophagus,  442 

of  stomach  in  toxic  gastritis,  449 
Stroke  cultures,  747 
Strongyloides  intestinalis,  278 
Strongylus  duodenalis,  275 
Strongylus  paradoxus,  278 
Strumitis,  316 
Stuttering,  632 
Subacidity,  gastric,  471 
Subsultus  tendinum,  64 
Succussion  of  dilated  stomach,  457 
Sudamina  in  typhoid  fever,  67 
Suffusion,  15 
Sugar,  tests  for,  731 

quantitative  estimation  of,  ya 
Sulphates,  tests  for,  729 


Sulphuric-acid  intoxication,  6 
Summer  diarrhea,  481 
Sunstroke,  616 
Superacidity,  gastric,  471 
Supermotility,   gastric,  473 
Supersecretion,  gastric,  470 

of  salivary  glands,  435 
Suprarenal  atrophy,  311 

disease,   310 
Surgical  kidney,  573 
Susceptibility,  ;iy 
Swamp  fever,  239 
Sweating  in  trichinosis,  273 

in  tuberculosis,  201 

in  typhoid  fever,  67 
Sweating  sickness,  228 
Sydenham's  chorea,  680 
Syphilis,  162 

acquired,   163 

congenital,  167 

hemorrhagica  neonatorum,  305 

insontium,   163 

of  digestive  system,  164 

of  lung,   165 

of  nervous  system,  165 

stages  of,  163 
Syringomyelia,  653 

Schlesinger's  classification  of.  654 

Tabes  dorsalis,  647 
Tache  c^rebrale,  66 

in  tuberculosis,  181 
Tachycardia,  365 

in  exophthalmic  goiter,  318 

in  influenza,  8s 

in  pneumogastric  disease,  630 
Tapeworms,  279 
Teeth  in  congenital  S3'philis,  166 
Telegrapher's  cramp,  699 
Temperature,  normal  control  of,  19 

of  acute  meningitis,   181 

of  acute  rheumatism,  156 

of  acute  yellow  atrophy,  5 16 

of  cerebrospinal  meningitis,  112 

of  diphtheria,  132 

of  erysipelas,  153 

of  German  measles,  109 

of  measles,   107 

of  pneumonia,   119 

of  pyemia,   151 

of  rotheln,  109 

of  scarlatina,  102 

of  typhoid  fever,  55 
Temperature-sense    lost   in   s^ririgomyelia, 

subnormal,  in  appendicitis,  493  • 
in  cerebral  hemorrhage,  663 
in  hydrophobia,  231 
in  lead-poisoning,  611 
in  malaria,   245 
in  tubercular  peritonitis,   18S 
in  tuberculosis,  200 
in  spotted  fever  of  Rocky  Moun- 
tains, 228 


INDEX 


777 


Tenderness  in  appendicitis,  404 
Tenia,   279 

armata,  279 
confusa,  280 
cucumerina,  280 
diminuta,  280 
echinococcus,  28J 
elliptica,  280 
flavopunctata,  280 
lata,  280 

Madagascarensis,  280 
mediotanellata,  280 
nana,   280 
saginata,  280 
solium,  279 
Tenioidea,  279 
Tenosynovitis,  162 
Terminal  pneumonia,  123 
Test-Meals,  719 
Testicle,  tuberculosis  of,  211 
Testis,  involved  in  mumps,  145 
Tests:  alizarin,  722 
Boas's,  720 

Bottger's,  for  sugar,  732 
Bremer's,  of  diabetic  blood,  71 S 
Fehling's,  for  sugar,  732 
fermentation,  for  sugar,  7:^3 
for  blood,  718 

Gmelin's,  for  bile  pigment,  7  5  |. 
guaiacum,  718 
Giinzburg's,  720 
hemin,  718 

Haines's,  for  sugar,  2:^2 
Heller's,  for  bile,  734 

for  iodin,  734 
Heller-Moore,  for  sugar,  y,^^ 
McMunn's,  for  indican,  734 
murexid,  728 
of  stomach-contents,  719 
of  stomach-contents,  for  albumin,  721 

for  albumose,  721 

for  blood,  721 

for  fatty  acids,  721,  723 

for  free  acids,  720,  722 

for  hydrochloric  acid,  720,  722 

for  lactic  acid,  720,  723 

for  organic  acids,  720,  723 

for  pepsin,  721 

for  pepton,  721 

for  propepton,  721 

for  proteids,  y2i 

for  rennet,  721 
of  urine,  for  acetanilid,  735 

for  albumin,   730 

for  alkapton,  731 

for  antipyrin,  735 

for  arsenic,  734 

for  bile,  734 

for  bromin  and  iodin,  735 

for  carbonates,  730 

for  chlorids,  729 

for  creatinin,  729 

for  ferments,  729 

for  fibrin.   731 


Tests:  of  urine,  for  globulin,  731 
for  hemoglobin,  731 
for  indican,  734 
for  lead,  735 
for  mercury,  735 
for  morphin,  735 
for  phosphates,  729 
for  pine-acids,  736 
for  quinin,   735 
for  rhubarb  and  senna,  j;i6 
for  salicylic  acid,  736 
for  santonin,  736 
for  sugar,  731 
for  sulphates,  729 
for  urea,  728 
for  uric  acid,  728 
for  xanthin,  728 
Pettenkofer's,  for  bile-acids,  734 
phenylhydrazin,  732 
picric-acid,  for  albumin,  730 

for  sugar,  733 
Reinsch's,  for  arsenic,  734 
Rosenbach's,  for  bile,  734 
salol,  for  gastric  motion,  724 
Topfer's,  720 
Trommer's,  731 
Ultzmann's,  for  bile,  734 
Williamson's,  of  diabetic  blood,  71S 
Wood's  for  lead,  735 
Tetanilla,  688 
Tetany,  688 

in  cholera  infantum,  483 
in  dilatation  of  stomach,  457 
in  rickets,  594 
rheumatic,  688 
Tetanus,  223 
Tetrads,  ;i3 
Thermic  fever,  616 
Thomsen's  disease,  619 
Threadworms,  271 
Thrill,  aneurismal,  ;i76 

basic,  in  aortic  stenosis,  346 
of  mitral  incompetency,  339 
suprasternal,  in  aortic  lesions,  344 
Thrombosis,  15 

in  high  altitudes,  227 
in  influenza,  83 
in  pyemia,   151 
in  scarlatina,  104 
in  typhoid  fever,  58 
marantic,  of  brain,  659 
marasmic,  17 
of  brain,  666 

of  cerebral  sinuses  and  veins,  659 
of  spinal  cord,  6;^^ 
Thrombus,  15 

ante-mortem,  340 
ball,  340 
varieties  of,   16 
Thrush,  431 

Thymus  gland,  diseases  of,  321 
Thyroid  gland,  diseases  of,  315 

tumors  of,  321 
Thyroiditis,  315 


778 


INDEX 


Thyroiditis,  after  typhoid  fever,  59 
Tibial  curvature  in  rickets,  594 
Tic,  convulsive,  682 

douloureux,  691 
Tick  as  a  parasite,  287 
Tinnitus,  629 
Tongue,  diseases  of,  434 

eczema  of,  435 

epithelioma  of,  435 

features  of,  in  diphtheria,  132 
in  influenza,  82 
in  scarlet  fever,  loi 
in  typhoid  fever,  59 

"raspberry,"  loi 

"strawberry,"    loi 
Tonsils,  diseases  of,  439 

tuberculosis  of,  206 
Tonsilitis,  acute,  439 

catarrhal,  follicular,  ulcerative,  439 

chronic,  440 

herpetic,  439 

in  endocarditis,  330 

suppurative,  439 
Tophi  in  gout,  590 
Torticollis,  586 

acquired,  631 

congenital,  631 

in  spinal  accessory  disease,  631 
Toxalbumins,  35 
Toxins,  35 

affinities  of,  41 
Toxoid,  41 
Toxon,  ;i6 

Toxophore  groups  of  cells,  41 
Tracheal  tugging,  376 
Tracheotomy  in  diphtheria,  141 
Traube's  theory  of  angina,  367 

of  uremia,  560 
Traumatic  hysteria,  700 
Treitz's  hernia,  498 
Trematodes,  7,  269 
"Trembles"  of  cattle,  237 
Tremor,  hereditary,  680 

hysterical,  680 

in  alcoholism,  607 

in  arsenical-poisoning,  613 

in  exophthalmic  goiter,  318 

in  insular  sclerosis,  672 

in  paralysis  agitans,  678 

postparalytic,  664 

senile,  680 

simple,  679 

toxic,  679 
Trichina   spiralis,  272 
Trichiniasis,  271 
Trichinosis,  271 
Trichomonas,  caudata,  elongata,  268 

flagellata,  intestinalis,  vaginalis,  268 
Tricuspid  insufficiency,  347 

stenosis,  347 
Trigeminus  nerve,  diseases  of,  626 
Trigemism  of  heart,  364 
Trismus  from  disease  of  fifth  nerve,  262 

neonatorum,  223 


Trommer's  test  for  sugar,  731 
Trophic  disturbances  in  neuritis,  622 
Trousseau's  mark  in  acute  meningeal  tuber- 
culosis, 181 

symptom  in  tetany,  688 
Tubercle,  formation  of,  175 

large  solitary*  of  aorta,  206 
of  brain,  205 
of  liver,  208 
Tubercula  dolorosa,  623 
Tubercular  infiltration,  176 
Tuberculin  test,  212 
Tuberculosis,  169 

acute,  177 

typhoid  form,  178 

acute  disseminated,  177 

acute  meningeal,  179 

acute  miliary,  177 

acute  pneumonic,  192 
after  measles,  108 

bronchopneumonic,  193 

by  ingestion,  172 

by  inhalation,  172 

by  inoculation,  173 

chronic,  of  lung,  194 

diagnosis  of,  212 

environment  in,  174 

from  meat,  172 

from  milk,  172 

general,  169 

general  treatment  of,  215 

hereditary,  transmission  of,  171 

in  diabetes,  599 

localized,  182 

modes  of  infection  in,  170 

of  arytenoid  cartilages,  190 

of. central  nervous  system,  205 

of  cerebellum,  205 

of  circulatory  system,  205 

of  digestive  system,  206 

of  epiglottis,  190 

of  fauces,  190 

of  female  generative  organs,  211 

of  genitourinary  system,  208 

of  intestine,  206 

of  kidney,  209 

of  larynx,  190 

of  liver,  208 

of  lung,  191 

typical  course  of,  196 

of  lymphatic  system,  187 

of  mammae,  211 

of  nose,  190 

of  pancreas,  208 

of  pericardium,   186 

of  peritoneum,  187 

of  pleura,  185 

of  respiratory  system,  190 

of  serous  membranes,  185 

of  spleen,  20S 

of  vocal  cords,   190 

physical  signs  of,  201 

predisposing  causes  of,  173 

prognosis  of,  213 


INDEX 


779 


Tuberculosis,  prophylaxis  of,  214 
pulmonary,  191 
sources  of  infection  in,  191 
specific  treatment  of,  220 
Tufnell's  diet,  t^-j-j 
Tunnel-anemia,  275 
Tussis  convulsiva,  142 
Typhoid  bacillus,  49 

in  pleurisy,  418 

in  pneumonia,  116 
pneumonia,  123 
spine,  64 
Typhoid  fever,  47 

abortive,  54 

afebrile,  54 

ambulatory,  54 

associated  acute  infections,  68 

complications  of,  55 

diagnosis  of,  69 

eruption  of,  66 

facial  aspect  in,  55 

fulminant  form  of,  54 

general  course  of,  51 

hyperpyrexia  in,  56 

immunity  from,  48 

in  children,  55 

in  pregnant  women,  55 

in  the  aged,  55 

inoculation  treatment  of,  "jS 

preventive  inoculation,  "j^i 

pulse  in,  58 

recrudescence  of,  68 

relapses  in,  68 

sudoral,  67 

susceptibility  to,  48 

symptoms  of,  51 

temperature  of,  55,  76 

treatment  of,  72 

types  of,  49,  54 

"walking,"  54 
Typhomania,  677 
Typhus,  abdominal,  47 

exanthematic,  47 
Typhus  fever,  78 
relapsing,  80 
Tyrosin,  a  bacterial  product,  ^6 

in  the  urine,  y^^j 
Tyrotoxicon-poisoning,  614 
Twists  and  knots  of  bowel,  499 

Ulcer,  corneal,  in  measles,  108 
esophageal,  442 

follicular  or  catarrhal,  of  bowel,  487 
peptic,  459 

perforating,  in  diabetes,  599 
in  leprosy,  222 
or  rodent,  of  stomach,  459 
rectal,  in  locomotor  ataxia,  649 
stercoral,  487 
Ulceration,  intestinal,  in  typhoid  fever,  50 
Ulcerative  colitis,  487 
endocarditis,  331 

due  to  gonorrheal  infection,  162 
Ulnar  nerve,  disease  of,  62tJt 


Uncinaria  duodenalis,  275 
Undulant  fever,  97 
Urates  in  lithuria,  558 

in  urine,  J2fi 
Urea,  tests  for,  728 
Uremia,  560 

acute  and  chronic,  561 

theories  of,  560 

treatment  of,  572 
Ureter,  tuberculosis  of,  210 
Urethra,  tuberculosis  of,  210 
Urethritis  in  gout,  592 

in  typhoid  fever,  (y6 
Uric-acid  crystals,  736 

excess  of,  in  urine,  558 

in  acid  intoxication,  6 

tests  for,  728 
Urinary  sediments,  •J2>^ 
Urine,  character  of,  in  acute  rheumatism, 

in  amyloid  kidney,  573 

in  chronic  nephritis,  568,  570 

in  diabetes,  599 

in  jaundice,  531 

in  pyelitis,  574 

in  pyemia,  151 

in  renal  tuberculosis,  209 

in  scarlatina,  102 
examination  of,  y2j 
retention  of,  in  peritonitis,  545 
toxicity  of,  in  sunstroke,  617 

in  typhoid  fever,  65 
Uroleucinic  acid  in  urine,  560 
Uroxanthic  acid  in  urine,  560 
Urticaria  in  jaundice,  531 
Uvula,  paralysis  of,  in  diphtheria,  135 

Vaccination,  265 

complications  of,  266 
Vaccinia,  265 

generalized,  266 
Valvular  disease  of  heart,  335 
remote  effects  of,  2>2fi 

lesions,  association  of,  348 
treatment  of,  349 
Varicella,  266 
Variola,  256 

benigna,  261 

maligna,  261 

vera,  259 
Varioloid,  261 
Varix  of  esophagus,  445 
Vasomotor  and  tropic  disorders,  701 
Vegetations,  endocardial,  330 

verrucose,   in  malignant  endocarditis, 
332 
Vertigo,  auditory,  629 

labyrinthine,  629 
Visceroptosis,  507 
Vocal  cords,  tuberculosis  of,  190 
Volvulus  of  intestine,  499 

of  stomach,  456 
Vomiting  in  acute  uremia,  561 

in  peptic  ulcer,  461 


780 


INDEX 


Vomiting  in  typhoid  fever,  60 

nervous,  473 

stercoraceous,  in  intestinal  obstruction, 
500 
Vomitus,  examination  of,  724 

in  cancer  of  stomach,  465 

in  cholera  infantum,  483 

in  dilated  stomach,  457 
Vulvovaginitis  in  mumps,  145 

Wandering  spleen,  313 

Wasting  palsy,  645 

Water  and  other  fluids,  examination  of,  749 

infection  by,   in   typhoid  fever,  48 
Weil's  disease,  225 
Welch's  capsule  stain,  744 
Westphal's  symptom,  648 
Weyl's  test  for  creatinin,  729 
Whooping-cough,  142 

associated  with  measles,  108 
Widal's  serum  test,  717 
Winckel's  disease,  305 
Winter  cough,  390 
Wool-sorters'  disease,  232 
Word-deafness,  629,  675 


Word-dumbness,  674 

Worms,  270 

Wound  diphtheria,  135 

septicemia,  150 
Wrisberg,  nerve  of,  injury  of,  628 
Wrist-drop  due  to  lead-poisoning,  611 
Writer's  cramp.  699 
Wry-neck  (see  Torticollis),  5S6 

Xanthelasma  in  jaundice,  531 
Xanthin,  6 

test  for,  728 
Xanthopsia  due  to  santonin,  271 

in  jaundice,  531 
Xerostomia,  436 

Yeast-fungus  in  cancer  of  stomach,  466 

in  dilated  stomach,  457 

in  the  urine,  740 
Yellow  fever,  89 

varieties  of,  92 
Yersin-Roux  serum,  97 

Ziehl's  carbol-fuchsin  solution,  743 
Zona,  692 


V'?.'^ 


